Case Manager II - Portland
Location: Portland Maine
Description: Martin's Point Health Care is currently seeking to employ Case Manager II - Portland right now, this position will be placed in Maine. More complete informations about this position opportunity please read the description below. The Case Manager works collaboratively within the HMD team to ensure high quality care, service and cost effective outcomes are achieved for the MPHC member population.! Case managers have expertise in multiple areas of specialty and work within integrated teams to ensure member centric focus. Areas of specialty include: medical benefit review; concurrent utilization management; complex case management; and, population health disease management. The Case Manager is cross trained to support end to end management of patient care.
The Case Manager works with members along the health continuum. Primary responsibilities include implementing strategies designed to facilitate the appropriate use of health care resources while ensuring that each client has the opportunity to reach optimal health status through appropriate, quality care. This is accomplished through extensive coordination of services across the continuum, assuring appropriate level of care, anticipating future health care needs, decreasing fragmentation of care, and identifying alternative care plans.
The role requires the ability to analyze and research current s! tandards of care using national recognized criteria. The Case ! Manager also acts as a facilitator in the medical appeal process. The case manager collects medical information for medical reviews for second opinions and medical appeals.
The Case Management process is based on both the American Nurses Association (ANA) and the Case Management Society of America (CMSA) standards and includes assessment, problem and need identification, long and short term goals, care management plan, and outcome evaluation, as applicable, to benefit position.
Overall Results Areas:
Collaborates with healthcare providers and members to optimize member benefits and to promote effective utilization of resources.
Applies evidence based criteria, e.g. Milliman, Centers for Medicare Services Physician Quality Reporting Initiative (PQRI), HEDIS in clinical decision making and care management processes and interventions
Manages health care within the benefits structures per line of business and performs functions wit! hin compliance, contractual and accreditation regulations, e.g. Department of Defense, Centers for Medicaid and Medicare, URAC, NCQA, Employer contracts and state insurance regulations as applicable
Completes all documentation of interventions and outcomes consistent with MPHC program requirements in appropriate systems, according to process requirements and within timeliness standards.
Provides support to members, their families, and physicians in addressing medical and social concerns.
Educates members and families to make informed personal health care decisions.
Facilitates communications between member, physician, health plan and community resources.
Participates as a member of an interdisciplinary plan in transitions of care.
Acts as a liaison to ensure the member is receiving the appropriate level of care at the appropriate place and time.
Key Outcomes by Specialty Areas:
Complex Case Management!
Case management functions may include management of specific,! individual medical episodes identified through utilization and benefit review.
Develops and implements intervention strategies and plans of care in collaboration with member, family, physician, hospital and other related contacts to determine appropriateness of care from diagnosis to outcome .
Documents according to CM/UM program requirements, completes assessments, manages case load, reassigns skill levels and discharges patients in a timely manner and within guidelines as define in the CM/UM program
A score of 80% or higher will be maintained for all case management IRR audits.
Pre-Authorization and Benefit Review
Performs timely review of benefit determinations based on evidence based criteria, coverage requirements and defined standards of practice.
Appropriately refers cases to Medical Director for review in accordance with CM/UM program requirements.
A score of 90% or higher will be maintained for all ben! efit review IRR audits.
Concurrent Utilization Management
Completes assigned daily inpatient CM/UM functions, including concurrent and discharge planning in accordance with evidence based guidelines and standard criteria measurement criteria.
Completes discharge planning and post discharge assessments with 2 business days of patient discharge for all appropriate patients as defined by CM/UM program.
Identify, assess and refer appropriate members for care management/disease management and assist in post acute phases of care.
Population Health and Disease Management
Validates and initiates interventions for identified member
Completes assigned outreach and intervention plans according patient priority, uses appropriate interventions based on disease state needs and documents actions and outcomes’ according to CM/UM program.
Performs moderately complex analysis of outcomes and trends to help modify progr! am for greater effectiveness. Reviews and analyzes population data and ! metrics to inform development of programs and improved health outcomes.
Education/Experience:
Unrestricted state licensed registered nurse, BSN preferred
Minimum three (3) years clinical nursing experience and skill in patient assessment and care planning
Unrestricted multiple RN state licenses may be required as applicable within 6 month of employment
Knowledge of Scope of Nursing Practice in states where licensed
Skills/Knowledge/Competencies (Behaviors):
Maintains knowledge, and practices within, CMSA Case Management Standards of Care and Code of Professional Conduct guidelines.
Maintains current licensure and practices within scope of license(s) for geographic areas of practice.
Knowledge of evidence based guidelines application.
Excellent interpersonal, verbal and written communication skills
Critical thinking: can identify root causes and understands coordinat! ion of medical and clinical information
Ability to prioritize time and tasks efficiently and effectively
Ability to manage multiple demands
Ability to function independently
Computer proficiency in Microsoft Office products including Word, Excel, and Outlook
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If you were eligible to this position, please email us your resume, with salary requirements and a resume to Martin's Point Health Care.
If you interested on this position just click on the Apply button, you will be redirected to the official website
This position starts available on: Tue, 30 Jul 2013 21:31:32 GMT