DESCRIPTION/RESPONSIBILITIES:
Responsible for utilizing the nursing process in the development of treatment plans, with established goals, implementation, monitoring and evaluation of an assigned patient case loads in order to provide quality care appropriate to clinical needs.
Review and analyze referrals from a variety of sources for acceptance into the program. Evaluate patient needs, identify and recommend cost-effective health care options. Assure member health needs are consistent with nursing standards and practices, provide recommendations. Develop and monitor action plans established between member, family and/or designee and physician. Develop preauthorization review plans for the review of RN clinical cases. Make arrangements for DME supplies, medications, community resources and facilities. Educate patient and family and/or designee to processes, care practices, medication(s) and benefits. Review prescription drug coverage requests, transplant services, acute organ rejection episodes and/or requests for coverage. Prepare documentation, communicate findings and submit recommendations to medical policy, group representatives, and members of the health care team. (i.e. provider, subscriber, family). Coordinate the member appeals process for DOL, PA250/blended cases. Ensure clinical outcomes are met preventing future re-implantation. Review patient status, educate patient on self management and ensure appropriate levels of post care education are provided. Identify potential gaps in member discharge to be avoided through education, empowerment and/or motivational interviewing. Clinical review of claims to ensure that correct reimbursement occurs. Internal peer review for quality performance. May conduct patient home visits to guarantee that the setting is safe and medical services are delivered. Continues professional development by attending relevant educational programs at lease annually.
BEHAVIORAL HEALTH DEPARTMENTAL REQUIREMENTS:
Masters degree in Social Work, Psychology or a related Allied Health discipline preferred. Three (3) years of clinical experience treating mental health and substance abuse disorders required. Behavior Health and Medical Management processes across the continuum of care. Diagnostic criteria from DSM-IV-TR and ICD-9 and CPT coding. State and Federal HMO regulations preferred.
Departmental Preferences:
The case manager will provide behavioral health case management services to members with complex or co-morbid mental health/substance abuse and medical needs. Role includes collaboration with the member and providers to develop an individual plan of care including coordination of clinical services, education, and identification of community resources. This position will work with subscribers to review patient status, educate members on self-management skills and ensure appropriate levels of post care education and support are in place. This role also includes the identification of potential gaps in care following discharge from treatment. A strong skill set involving education, empowerment and motivational interviewing to engage members in case management services is required.
The case manager may also provide telephonic case review and authorization of services utilizing established mental health and substance abuse medical necessity criteria. The case manager evaluates the clinical appropriateness of requested services, coordinates care, assists with discharge planning and identifies members who may benefit from case and/or disease management. This position requires participation in the clinical call center in order to receive requests from members and providers regarding routine, urgent, and emergent behavioral health care needs. Other duties may be assigned.
Responsible for utilizing the care management process in the development of treatment plans, with established goals, implementation, monitoring and evaluation of assigned patient caseloads in order to provide quality care appropriate to clinical needs.
All qualified applicants will receive consideration for employment without regard to, among other grounds, race, color, religion, sex, national origin, sexual orientation, age, protected veteran status or status as an individual with a disability
VEVRAA Federal Contractor
Request Priority Protected Veteran Referrals
EOE -Veteran /Disabled/Minority/AA/F/M/SO
