The primary purpose is to deliver the clinical case management model resulting in consistent, collaborative and coordinated care based on member needs and risk profile. Identifying member needs begins with early identification of health risk factors, ongoing assessment, planning, invention, evaluation, education and prevention using the plan of care. Work as a complex case manager and manage individuals with complex conditions. Collaborates with inpatient team and Transition Care Nurse, and attends departmental meetings and Interdisciplinary Care Team meetings. Communicates with home health team, PCP and appropriate specialists about the member's goals and plan.
ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.
Regularly and dependably reports to work as scheduled. Follows all Company policies and procedures, including but not limited to personnel policies, safety policies and operational policies as communicated by management. Follows all Department policies and procedures, including, but not limited to procedural guidelines/workflows, attendance requirements and performance requirements as communicated by management. In accordance with State and/or Federal confidentiality/privacy laws, maintains confidentiality of all company, provider, member and client information as specified by Company confidentiality policies and procedures. Represents the Company in a professional manner at all times when dealing with both internal and external customers. Adheres to the MDX Hawai'i's HIPAA and Privacy Standards and Confidentiality Agreement. Engage enrollee and stratify:
Job Description - Case Manager
- Conducts the telephonic survey of English speaking enrollees following assessment guidelines. Utilizes the Health Plan's language line to obtain interpreters as needed for non-English speaking enrollees
- Responds with appropriate case management protocol by level of care assignment.
- Completes telephonic assessment.
- For high risk members, may require travel to hospitals, clinics or skilled nursing facilities, if requested by manager.
- Contact enrollee to explain case management process
Assess and develop plan of care:
- Completes appropriate assessment for care level in order to determine baseline status and identify patterns of functional decline
- Documents enrollee identified goals and creates interventions to address/achieve them
- Develops patient centered plan of care based on the enrollee identified needs, using interventions that are evidenced based
- Shares plan of care with appropriate members of the care team so care team members are working towards uniform member goals
- Utilizes multiple techniques to obtain assessment information including: family, caregivers, providers, etc.
H. Deliver and Coordinate services:
- Identifies formal and informal resources to meet the enrollee needs as stated in the plan of care.
- Enters service notifications according to guidelines
- Communicates with the member, primary care physician and community partners concerning clinical needs and case alternatives.
- Serves as member advocate and facilitator to resolve issues that may be barriers to care.
- Through developing a relationship with the member /family, the care nurse educates the member /family about their health conditions, treatment options, community resources, insurance benefits and psychosocial concerns so that informed decisions can be made and member self-management is promoted
- Ensures appropriate utilization and consistent application of the benefits
- Maintains time sensitive documentation including case management interventions and outcomes to assure compliance with program goals and regulatory agencies
Monitor and evaluate Outcomes:
- Organizes work and develops strategies for adapting to a constantly changing workload or when confronted with unseen situations
- Facilitates early identification of changes in condition so that effective treatment can be initiated promptly, reducing the need for preventable emergency room visits, nursing home placements and hospitalizations
- Provides Case management services in the community, including on-site and telephonic reassessments according to protocol.
- Monitors member's responses to the interventions and adjusts plan of care as needed.
- Monitors hospital and SNF admissions according to post hospital program and provides education and/or interventions as necessary to reduce frequency
Job Description - Case Manager
- Participates in the Quality Improvement process including the recognition of quality of care issues and forwarding information to appropriate staff for review and resolution
- Pre-authorization of inpatient, Skilled Nursing Facilities, DME, and therapies;
- Continued stay reviews for inpatient services (Acute, SNF)
- Initiates discharge planning through telephonic intervention with the facility;
- Collaborates with the site clinical team regarding discharge planning and Case management level changes.
- Completes telephonic post hospital assessment (per trigger criteria).
- Functions independently and responsibly with minimal supervision
- Maintains direct and open communication with all levels of the organization
- Demonstrates initiative in achieving individual, team, and organizational goals and objectives
- Organizes work and develop strategies for adapting to a constantly changing workload or when confronted with unforeseen situations
- Able to handle sensitive and confidential information
- Demonstrates holistic approach to Case management
- Acts as advocate for enrollee
- Demonstrates cultural competence and sensitivity to member population
EDUCATION AND/OR EXPERIENCE:
Graduate from an accredited school of nursing or graduate program in social work.
Two (2) years experience in case management or managed care preferred.
Bachelor of Science degree in nursing or other health related field. Other comparable experience considered.
LICENSES, CERTIFICATIONS, REGISTRATIONS: MSW - Two (2) years post graduate experience in a health care facility/setting. RN - ICU or emergency care experience preferred. Current/valid Hawai'i Driver's License. Proof of Hawai'i No-Fault Auto Insurance. Clean driving record as evidenced by a recent driver's abstract (to be provided by the employee).