This is a field-based position requiring approximately 50–75% travel, with an expectation of being in the community 2–3 days per week to conduct member visits and care management activities. When not in the field, work is completed remotely from home, including telephonic outreach and documentation. Caseloads are assigned using a point-based system, with size varying based on member stratification and acuity, ensuring a balanced workload aligned to complexity and care needs. The Case Manager utilizes a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual's benefit plan and/or health needs through communication and available resources to promote optimal, cost-effective outcomes. Requires an RN with unrestricted active license.
Through the use of clinical tools and information/data review, conducts comprehensive assessments of referred member's needs/eligibility and determines approach to case resolution and/or meeting needs by evaluating member's benefit plan and available internal and external programs/services. Application and/or interpretation of applicable criteria and guidelines, standardized case management plans, policies, procedures, and regulatory standards while assessing benefits and/or member's needs to ensure appropriate administration of benefits. Utilizes case management and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures.
Experience: 3 years clinical practice experience, e.g., hospital setting, alternative care setting such as home health or ambulatory care required. Healthcare and/or managed care industry experience. Case Management experience preferred. Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding. Effective communication skills, both verbal and written. Ability to multitask, prioritize and effectively adapt to a fast paced changing environment.
Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer. Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor. Typical office working environment with productivity and quality expectations. Education: RN with current unrestricted state licensure for MI. Case Management Certification CCM preferred.
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