Description:
GENERAL SUMMARY
Functions as the central coordinator of care for members/injured employees identified as having chronic disease processes or for members/injured employees in select physician practices. Responsible for implementing and coordinating all case management activities relating to catastrophic cases and chronically ill members/injured employees across the continuum of care including consultant referrals, home care visits, use of community resources, and alternative levels of care. May be responsible for developing and executing implementation plans with a physician practice to coordinate all case management activities. Uses computer-based systems to review medical experience of members/injured employees and interact with staff. This position may specialize within a disease area.
ESSENTIAL RESPONSIBILITIES
- Responsible for the comprehensive management of members/injured employees with a catastrophic illness or for members/injured employees in select physician practices.
- Responsible for the proactive management of chronically ill members/injured employees with the objective of improving quality outcomes and decreasing costs.
- Responsible for the early identification and assessment of members/injured employees for admittance to a comprehensive case management program.
- Applies case management concepts, principles, and strategies in the development of an individualized case plan that addresses the member's/injured employee's broad spectrum of needs. The case planning process includes the following actions: assessment, goal setting, establishing interventions related to goals, monitoring success of the interventions, evaluating the success of the overall case plan, and reporting outcomes.
- Interviews members telephonically, in their home, physician office or in other facilities to provide initial and ongoing case management services.
- Conducts regular discussions and updates with the member's primary care physicians, other providers including behavioral health providers, health plan Medical Directors, health services staff, or the injured employee's insurance company and employer regarding the status of a particular member/injured employee.
- Serves as the member/injured employee's advocate to ensure they receive all necessary care allowed under their benefit plan. Develops knowledge of community resources and alternate funding arrangements available to the member/injured employee when services are not available under their benefits program.
- Develops new programs as appropriate to reduce admissions for acute and chronic members/injured employees and assist with decreasing their lengths of stay.
- Develops relationships with hospital social workers and community resources to assure appropriate management of catastrophic and chronically ill members/injured employees.
- Develops an understanding of healthcare reimbursement methods that promotes the provision of cost effective healthcare and the preservation of the member/injured employee benefits.
- Assists in the identification and reporting of potential quality improvement issues. Responsible for assuring these issues are reported to the Quality Improvement Department.
- May serve as a consultant to the physician network(s) to insure overall improvement in quality of medical care and outcomes.
- May serve as liaison and key resource for Appeals Coordinators for cases involving utilization management, case management, and general medical issues.
- May be responsible for handling sensitive appeal cases that involve complex medical issues assuring all regulatory requirements are met. Works closely with senior management and the Legal Department on these cases. May work with worker's compensation defense and plaintiff attorneys and testify as required.
- May be responsible for comprehensive management of appeal cases for members/injured employees involving transplants.
- Maintains confidentiality of member's/injured employee's information in accordance with HIPAA regulations.
- Performs other duties as required.
Qualifications:
JOB SPECIFICATIONS
- Registered nurse with active state license.
- Bachelor's degree or equivalent experience preferred.
- Complies with all state certification requirements in the state where job duties are performed.
- Previous experience (usually 1+ year) in case management.
- Significant experience (usually 3+ years) clinical experience.
- If required by URAC/NCQA accreditation, or the health plan, case management certification must be obtained within 4 years of date of hire.
- Utilization management experience and knowledge of community resources preferred.
- Experience with using computer systems as part of the clinical activity.
- Regular local travel may be required.Coventry Health Care is an Affirmative Action/Equal Opportunity Employer, and we are committed to building a talented and diverse team.
Job: Professionals
Primary Location: Louisville, KY, US
Other Locations: ,
Organization: 38500 - Coventry Health & Life-KY
Schedule: Full-time
Job Posting: 2013-11-21 00:00:00.0
Job ID: 1313572
GENERAL SUMMARY
Functions as the central coordinator of care for members/injured employees identified as having chronic disease processes or for members/injured employees in select physician practices. Responsible for implementing and coordinating all case management activities relating to catastrophic cases and chronically ill members/injured employees across the continuum of care including consultant referrals, home care visits, use of community resources, and alternative levels of care. May be responsible for developing and executing implementation plans with a physician practice to coordinate all case management activities. Uses computer-based systems to review medical experience of members/injured employees and interact with staff. This position may specialize within a disease area.
ESSENTIAL RESPONSIBILITIES
- Responsible for the comprehensive management of members/injured employees with a catastrophic illness or for members/injured employees in select physician practices.
- Responsible for the proactive management of chronically ill members/injured employees with the objective of improving quality outcomes and decreasing costs.
- Responsible for the early identification and assessment of members/injured employees for admittance to a comprehensive case management program.
- Applies case management concepts, principles, and strategies in the development of an individualized case plan that addresses the member's/injured employee's broad spectrum of needs. The case planning process includes the following actions: assessment, goal setting, establishing interventions related to goals, monitoring success of the interventions, evaluating the success of the overall case plan, and reporting outcomes.
- Interviews members telephonically, in their home, physician office or in other facilities to provide initial and ongoing case management services.
- Conducts regular discussions and updates with the member's primary care physicians, other providers including behavioral health providers, health plan Medical Directors, health services staff, or the injured employee's insurance company and employer regarding the status of a particular member/injured employee.
- Serves as the member/injured employee's advocate to ensure they receive all necessary care allowed under their benefit plan. Develops knowledge of community resources and alternate funding arrangements available to the member/injured employee when services are not available under their benefits program.
- Develops new programs as appropriate to reduce admissions for acute and chronic members/injured employees and assist with decreasing their lengths of stay.
- Develops relationships with hospital social workers and community resources to assure appropriate management of catastrophic and chronically ill members/injured employees.
- Develops an understanding of healthcare reimbursement methods that promotes the provision of cost effective healthcare and the preservation of the member/injured employee benefits.
- Assists in the identification and reporting of potential quality improvement issues. Responsible for assuring these issues are reported to the Quality Improvement Department.
- May serve as a consultant to the physician network(s) to insure overall improvement in quality of medical care and outcomes.
- May serve as liaison and key resource for Appeals Coordinators for cases involving utilization management, case management, and general medical issues.
- May be responsible for handling sensitive appeal cases that involve complex medical issues assuring all regulatory requirements are met. Works closely with senior management and the Legal Department on these cases. May work with worker's compensation defense and plaintiff attorneys and testify as required.
- May be responsible for comprehensive management of appeal cases for members/injured employees involving transplants.
- Maintains confidentiality of member's/injured employee's information in accordance with HIPAA regulations.
- Performs other duties as required.
Qualifications:
JOB SPECIFICATIONS
- Registered nurse with active state license.
- Bachelor's degree or equivalent experience preferred.
- Complies with all state certification requirements in the state where job duties are performed.
- Previous experience (usually 1+ year) in case management.
- Significant experience (usually 3+ years) clinical experience.
- If required by URAC/NCQA accreditation, or the health plan, case management certification must be obtained within 4 years of date of hire.
- Utilization management experience and knowledge of community resources preferred.
- Experience with using computer systems as part of the clinical activity.
- Regular local travel may be required.Coventry Health Care is an Affirmative Action/Equal Opportunity Employer, and we are committed to building a talented and diverse team.
Job: Professionals
Primary Location: Louisville, KY, US
Other Locations: ,
Organization: 38500 - Coventry Health & Life-KY
Schedule: Full-time
Job Posting: 2013-11-21 00:00:00.0
Job ID: 1313572
