You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility.Position Purpose: Utilizes care coordination tools, criteria and protocols to provide care coordination to lower acuity members with acute and chronic health care needs. Provides education and support in assisting members to achieve optimal level of wellness. Works in the field with member to support compliance with care and treatment plans in collaboration with the interdisciplinary care team. Meets with clients in their homes, work-sites, physician’s or hospital to provide management of services.
Perform member interviews to assist with gathering of information
Perform follow up with members engaged in case management
Facilitate provider contact as needed to coordinate member's care needs. Initiates appropriate referrals and inputs authorizations as needed for members active in case management.
Support the identification of high-risk members for disease or case management needs and works with member, physician and other Health care providers to meet the member's individual needs.
Identifies and escalates member cases with complex medical needs to Supervisor or Manager.
Act as liaison and member advocate between the member/family, physician and facilities/agencies.
Coordinates community resources, with emphasis on medical, behavioral, and social services. Applies case management standards, maintains HIPAA standards and confidentiality of protected health information and reports critical incidents and information regarding quality of care issues.
Instructs the member on how to access the program resources, suggest and/ or arrange follow-up including mailing of educational materials, contact with community resources, facilitate physician visits.
Documents all contacts in the Health Services clinical documentation system.
Manage members in disease management program, completing and revising as necessary, the information in clinical documentation system.
Ensures compliance with all state and federal regulations as well as Corporate guidelines in day-to-day activities.
Meets with clients in their homes, work-sites, physician’s or hospital to provide management of services.
Adapts to changes in policies, procedures, new techniques and additional responsibilities.
Participates with other Case Managers and Medical Directors in regular or special meetings such as Clinical rounds.
Complies with all guidelines established by the Centers for Medicare and Medicaid (CMS) and guidelines set forth by other regulatory agencies, where applicable, and Corporate and department policies and procedures.
Identifies potential quality of care issues and appropriately refers to the quality department.
Assists in the implementation of specific strategies that improve the quality and outcomes of care.
Educates members and facilitates HEDIS gap closure.
Performs all other duties assigned.
Works under direct supervision of a Registered NurseAdditional Responsibilities: Travel to inpatient bedside, member’s home, provider’s office, hospitals, etc required with dependable car. May spend up to 70% of time traveling with exposure to inclement weather and normal road hazards. May require climbing multiple flights of stairs to a member's home, provider's office, etc.
Candidate Education: Required A High School or GEDPreferred An Associate's Degree in nursingCandidate Experience: Required 2+ years of experience in utilization management and/or case management in a hospital or home health setting or with a managed care organization.Preferred Other prior experience working with a geriatric populationLicenses and Certifications: A license in one of the following is required: Required Other Current unrestricted LPN/LVN state licensePay Range: $22.36 - $38.07 per hourCentene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law. Total compensation may also include additional forms of incentives.Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.
