Basic Function : This position is responsible for conducting home health assessment, contacting identified members to inform and educate them on health care programs to address their personal health plan needs, engaging the member in discussion of adherence to personal health plans, responding to inquiries from members, and supporting the clinicians in the Medical Management department with their provider and member activities.

ESSENTIAL FUNCTIONS :

• Responsible for home health assessments and system updates.
• Build relationships with members to encourage compliance with care plans and to alert the Case Manager quickly when issues arise.
• Inform and educate members on their program, may use supplied scripts. Complete records in system by performing data entry.

Encourage member usage of our programs, including arranging appointments and additional member services (e.g., transportation).

Generate appropriate correspondence and send to member manually, electronically, or telephonically.

• Conduct check-ins with members to review individual care plan goals.
• Maintain production requirements based on established department business needs.
• Provide support to the clinical team by performing the non-clinical functions (as identified by the business process) necessary to generate, manage, and close a case within the platform.
• Receive, analyze, conduct research and respond to telephone and / or written inquiries. Process information from member or provider to determine needs / wants and ensure customer questions have been addressed.

Respond to customer or send to appropriate internal party.

• Notify help desk of system issues.
• Perform data entry function to update customer or provider information.
• Obtain required or missing information via correspondence or telephone.
• May serve as contact for the various groups regarding claims which involves conducting research, obtaining medical records / letters of medical necessity from TMG, reopen or initiate new cases as needed and refer case to clinicians.
• Support and maintain communications with various in-house areas regarding groups? concerns, i.e. : Marketing, Provider Affairs, and SSD.
• Communicate and interact effectively and professionally with co-workers, management, customers, etc.
• Comply with HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies and other applicable corporate and departmental policies.
• Maintain complete confidentiality of company business.
• Maintain communication with management regarding development within areas of assigned responsibilities and perform special projects as required or requested.

Job Requirements :

• Bachelor of Social Work or Psychology OR LVN, LPN with 1 year experience in managed care systems OR RN OR 3 years care coordination for a state managed or waiver program OR 3 years managed care systems experience
• Knowledge of medical terminology
• Experience coordinating member medical related needs, providing assistance to members, and analyzing member needs
• PC proficiency including Microsoft Office applications
• Customer service skill
• Verbal and written communications skills including developing written correspondence to members and to other department personnel and coaching skills, including motivational interviewing, to educate members on medical issues
• Current state driver license, transportation, and applicable insurance
• Ability and willingness to travel

Required Qualifications :

LSW, LPN, LPC

Last updated : 2024-05-15