Responsibilities

Job Summary:

Under the supervision of the Case Management Program Manager, the Case Manager (CM) is responsible for providing case management services for medically and/or socially complex members. The target member population includes individuals with significantly complex medical conditions, and/or social-economic, or mental health needs. The goal of the program is to assist these members in achieving optimal health and/or independence in managing their care. To achieve this goal the Case Manager will demonstrate and apply knowledge of the philosophy/principles of comprehensive case management, patient-centered, culturally sensitive care coordination, and management of complex members. The Case Manager will adhere to the CMSA Standards of Practice for Case Management.

The Case Manager is responsible for developing comprehensive care plans for member and family self-care competence, including motivational assessment, assessing for desired level of involvement, and coaching for adherence to the care plan. The CM assesses the member’s needs, and creates and monitors a specific individualized care plan, including end of life planning. The CM promotes knowledge of the Case Management program to Prominence Health Plan contracted physicians, as well as members. In addition, s/he is responsible for developing and sustaining partnerships with community resources and support agencies.

Qualifications

Job Duties/Responsibilities:

• Assess the physical, functional, social, psychological, environmental, learning, and financial needs of members.
• Identify problems, goals and interventions designed to meet members’ needs, including prioritized goals that consider the member/caregiver goals, preferences, and desired level of involvement in the case management plan.
• Create care plans that include objectives, goals and interventions designed to meet the member’s needs.
• Provide appropriate interventions which demonstrate knowledge of and sensitivity toward cultural diversity and religious, developmental, health literacy, and educational backgrounds of the population served. Utilize interpreter services per policy.
• Facilitates problem solving and decision-making by providing guidance, plan benefit knowledge, knowledge of disease management systems, wellness resources, and support services and options to the member, family and health care providers.
• Evaluate member’s progress toward goal achievement, including identification and evaluation of barriers to meeting or complying with the case management plan of care, and systematically reassess for changes in goals and/or health status.
• Research alternative treatment options. Locate appropriate providers, using network providers wherever possible.
• Participates in care conferences to enhance communication and promote continuity of care.
• Utilize motivational interviewing skills to build member engagement in case management plan of care.
• Act as a member advocate. Assist with problem solving and addressing any barriers to care or compliance with care plan.
• Provide referrals to appropriate community resources; facilitate access and communication when multiple services are involved; monitor activities to ensure that services are actually being delivered and meet the needs of the member, coordinate services to avoid duplication.
• Assess the patient’s formal and informal support systems, including caregiver resources and involvement as well as available benefits and/or community resources.
• Engage in professional development activities to keep abreast of case management practices and patient engagement strategies.
• Other health management related functions to meet department needs as required.
• Maintains departmental standards of accuracy including an understanding of Medicare and Medicaid regulations as they pertain to care management.

Requirements:

• Graduation from an accredited nursing education program, BSN or MSN preferred; OR BS/MS in Public Health or related field
• Active, unrestricted license as a Registered Nurse in the state in which the CM practices
• Certified Case Manager (CCM) or Certified Professional in Healthcare Quality (CPHQ), or ability to obtain within the required time period
• 3 yrs minimum Case Management experience in a managed care environment required
• Recent (within past 3 years) working knowledge of Milliman Care Guidelines required
• 3 yrs minimum clinical medical/surgical nursing practice within a hospital setting
• Ability to effectively communicate in English and Spanish, both verbally and in writing required
• Experience working with the Medicare and Medicaid population segment preferred
• Knowledge of Medicare/ Medicaid processes and compliance standards