The Case Manager utilizes a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual benefit plan and/or health needs through communication and available resources to promote optimal, cost-effective outcomes.
Job Responsibilities:
- Through the use of clinical tools and information/data review, conducts comprehensive assessments of referred member's needs/eligibility and determines approach to case resolution and/or meeting needs by evaluating member's benefit plan and available internal and external programs/services.
- Application and/or interpretation of applicable criteria and guidelines, standardized case management plans, policies, procedures, and regulatory standards while assessing benefits and/or members needs to ensure appropriate administration of benefits.
- Utilizes case management and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures
Skills:
- 3 years Clinical practice experience, e.g., hospital setting, alternative care setting such as home health or ambulatory care required.
- Healthcare and/or managed care industry experience.
- Case Management experience preferred
- Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding
Education/Experience:
- RN with current unrestricted state licensure.
- Case Management Certification/ CCM preferred
