Duties/Responsibilities:
Provides case management services for assigned member caseloads which includes:
Pre-certification performing risk-identification, preadmission, concurrent, and retrospective reviews to evaluate the appropriateness and medical necessity of treatments and service utilizations based on clinical documentation, regulatory, and InterQual/MCG criteria
Assessment - identifying medical, psychological, and social issues that need intervention.
Coordination - partnering with PCP and other medical providers to coordinate treatments, collateral services, and service authorizations. Negotiates rates with non-partner providers, where applicable. Ensures appropriate access and utilization of a full continuum of network and community resources to support health and recovery
Documenting - documenting all determinations, notifications, interventions, and telephone encounters in accordance with established documentation standards and regulatory guidelines.
Reports and escalates questionable healthcare services
Meets performance metric requirements as part of annual performance appraisals
Monitors assigned case load to meet performance metric requirements
Functions as a clinical resource for the multi-disciplinary care team in order to maximize HF member care quality while achieving effective medical cost management
Assists in identifying opportunities for and facilitating alternative care options based on member needs and assessments
Occasional overtime as necessary
Additional duties as assigned
Minimum Qualifications:RN, LPN, LMSW, LMHC,LMFT, LCSWPreferred Qualifications:
Masters degree in a related discipline
Experience in managed care, case management, identifying alternative care options, and discharge planning
Certified Case Manager
Milliman knowledge
Knowledge of Centers for Medicare & Medicaid Services (CMS) or New York State Department of Health (NYSDOH) regulations governing medical management in managed care
Relevant clinical work experience
Intermediate Outlook, Basic Word, Excel, PowerPoint, Adobe Acrobat skills.
Demonstrated critical thinking and assessment skills to ensure member care plans are followed.
Demonstrated ability to manage large caseloads and effectively work in a fast-paced environment
Demonstrated professional writing, electronic documentation, and assessment skills.
WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.
