Case Manager
Company: CareFirst, Inc.Categories: Health Care
Job description:PURPOSE: Perform the essential activities of case management (assessment, planning, implementation, coordination, monitoring, and evaluation) to offer quality health care to meet CareFirst BCBS member’s broad spectrum of healthcare needs in a cost-effective manner. Address the member’s ongoing continuity of care needs through various health care settings and delivery modes of treatment (inpatient, outpatient, homecare setting, etc.). Involves communication with all relevant parties: member, family, physicians, and other health care providers to facilitate coordination of services and maximizes outcomes. Identify alternative care options to enhance effective and efficient use of community resources.
PRINCIPAL ACCOUNTABILITIES: Under the general direction of the Manager and Supervisor of Case Management the incumbent’s accountabilities include, but are not limited to the following
- 15% Assessment: the collection of in-depth information about a member’s health care needs and situation ( physical/psych-social factors, benefit systems/cost analysis, community resources, and service delivery) from various sources to develop a comprehensive case management care plan.
- 15% Planning: the process of determining specific objectives, goals, and actions designed to meet the member’s needs as identified in the assessment process. Goals developed will be action-oriented and time-specific. Coordinates care plan development with input from the member, family, physician, and other healthcare providers. Assures that funding, benefits, and /or community resources are available to implement the plan.
- 15% Implementation: to carry out the interventions identified in the care plan to accomplish the goals and positive outcomes for the member.
- 10% Coordination and delivery of services: organizing, securing, and integrating all the multiple components of the health care system to deliver those services that are needed by the member.
- 10% Monitor: ongoing process to determine the plan’s effectiveness. Documentation will reflect the frequent communication with the member, family, physician, and other health care providers to ascertain that the goals of the care plan are being met, understood, revisions made, and documented.
- 10% Evaluation: to determine the case management plan’s effectiveness in reaching desired outcomes/goals.
- 10% Outcomes: Responsible for return on investment (ROI) cost savings analysis which reports quantifiable impact, quality of care and /or quality of life improvements monthly for every member in case management.
- 10% Appropriate interaction with the Legal Department with any correspondence and to remain in compliance with State of Maryland regulations. Identify fraud and abuse and refers this to SIU. Assessing and determining the need to report cases to risk and Quality Management. Internal resource for any non-medical department or personnel.
- 5% Appropriate community visits (done at the home, hospital, skilled facilities, or MD office) are expected to assess and assist the pt/family for their healthcare needs.
SUPERVISORY RESPONSIBILITY: This position has no supervision over others.
SCOPE DATA: This position is responsible for ensuring the quality of health care services for the target population. Job requirements:
This position requires a RN license with a minimum of 3-5 years of medical and/or clinical experience in medical-surgical, community/home health care, case management, or related specialty field, and equivalent experience reviewing patient medical care and services. Demonstrates knowledge and competency in all types of medical necessity decisions, including inpatient care, sub-acute/skilled care, outpatient care, hospice care, and home health care.
Abilities/Skills: General knowledge of current standard of medical practice and insurance benefit structures to negotiate medical review decisions and interpret contract benefits and managed care guidelines. Working knowledge of Case Management process, standards, and understanding of managed care in Healthcare setting . Excellent analytical and problem solving skills in order to judge the medical necessity and appropriateness of patient services and treatments on a case by case basis. Understanding of PC and mainframe environment and the ability to analyze statistical data and access relevant information. Have effective written/verbal communication, ability to effect change, organize effectively, promote positive outcomes and empowerment for the member/family.
Preferred: BSN or CCM and prior experience with home care, case management and an understanding of managed care is desirable.
Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.
PHYSICAL DEMANDS: The physical demands described here are representative of those that must be met by an employee to perform the essential duties and responsibilities of the position successfully. Requirements may be modified to accommodate individuals with disabilities.
The employee is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The employee must frequently talk and hear. Weights of up to 25 pounds are occasionally lifted. Community visits are required. A car is necessary.