Case Manager
Location: Baltimore Maryland
Description: CareFirst BlueCross BlueShield is employing Case Manager right now, this position will be placed in Maryland. Further informations about this position opportunity please read the description below. 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 (specific goals for Case Management Department are determined on an annual basis in accordance with directives from the executive board of CareFirst BlueCross BlueShield):
CASE MANAGEMENT PROCESS
- Identification/Risk Stratification:) Engages members into the case management program (outreach and successful enrollment) using diagnostic cost grouper classification reports, which identify the relative risk score and illness burden. Identifying catastrophic health care users with significant health care costs in band one of the PCMH pyramid.
- Assessment: Conducts and documents a comprehensive assessment of the member’s health psych/social needs, including health literacy and deficits. Obtains verbal and written consent to initiate case management services. Gathers clinical which includes past medical history, medications, physical/psychosocial factors, cultural influences, evaluation of health care barriers to include: available support systems, available benefits, community resources, and treatment and medication compliance
- Planning: Proficient case management clinical knowledge and experience to coordinate integrated care-plan development involving the member, family, Hospital Transition of Care (HTC) nurse, Local Care Coordination (LCC) and Regional Care Coordinator (RCC), Primary Care Physician (PCP), specialists and other healthcare providers/vendors. Goals developed will be prioritized, action-oriented and time-specific to stabilize the complicated health care condition.
- Facilitation of Communication and Care Coordination: Executing the transition of care includes moving the member from one healthcare practitioner and setting to another as their healthcare needs change. One key responsibility of the case manager is to minimize the fragmentation of care services and adverse outcomes. Completes a review of service request containing all appropriate information (clinical, medical policy, contact/complex benefit structure, FDA treatment, clinical trials and drugs) to allow the medical director to make a medical necessity determination. Identifies and provide educational and community resources, support groups, pharmacy program and financial assistance and alternative payors (MA, WIC, Model Waiver, COBRA, SSDI etc.)
- Monitoring: Documentation will reflect the necessary communication with the member, family, physicians, and other health care providers to ensure the member’s progression in meeting the established care plan goals.
- Outcomes Management: Evaluate the extent to which the established goals in the plan of care have been achieved. Completes a monthly member-specific cost savings to demonstrate the efficacy, quality, and cost-effectiveness of the case management interventions in conjunction with the results of the member satisfaction survey.
- Portal Data Base: Case management documentation is completed in the web-based Provider Portal System
- Access Data Base: Critical system specific to support our daily referral assignment and correspondence generation management
- Claims: Assists in claims inquiries and resolution
- Legacy Systems (FEP Direct, CareFirst Direct, Facets, NASCO, Blue Web): Confirms member eligibility and available benefits
- Care Planner Web: Authorization management; generates coverage and adverse decision correspondence using appropriate language to meet state, federal and all regulatory requirements
- Employer Group/Accreditation Audits: Participates in the preparation and on-site reviews
- Knowledgeable of federal/state mandates as they apply to various plan contracts
- Documentation Audit: Responsible for completion of documentation review and self audit as assigned by management
- Milliman and Apollo Guidelines: Familiarity with and usage of for the purpose of discharge planning (and length of stay review for FEP Line of Business only)
- NCQA Compliance: Responsible for adherence to the NCQA Complex Case Management Standards
- CMSA: Adheres to the CMSA Standards of Practice for Case Management
- HIPAA: Maintains confidentiality of patient information according to HIPAA and departmental policies.
- Works with Legal Department counsel on contacts and member correspondence to ensure compliance with all the applicable State, Federal and Regulatory, and CareFirst and National policies.
- Identifies cases and refers to Risk Management OPL, Quality Management and Special Investigations Unit (SIU) for fraud and abuse
- Serves as internal resource for any non- nurses and support personnel.
- Other duties as assigned
- Current RN license with a minimum of 3 years of clinical experience in medical-surgical, community/home health care, case management, and equivalent experience reviewing patient medical care and services or one or more of the following specialties:
2. Pediatric Oncology or Adult Oncology
3. High Risk Pregnancy
4. Complex Medical Illnesses (e.g. MS, Lupus, Ulcerative Colitis)
5. Palliative Care/Hospice
6. Trauma/Rehab
- Excellent customer service
- Excellent verbal and written communications including telephone etiquette
- Excellent time management and prioritization skills, attention to detail, accuracy and quality awareness
- Excellent problem solving skills and knowledge base of medical necessity and appropriateness of patient services and treatments on a case by case basis.
- Excellent organizational skill, ability to multitask and work independently in a fast paced environment
- Ability to be flexible and adapt to change and promote a positive working environment and teamwork.
- Ability to demonstrate proficiency and accuracy in typing and computer skills during pre-employment testing
- BSN and/or CCM
- Prior experience with home care or case management and an understanding of managed care is highly preferred
- Strong PC skills, Microsoft Office (Word, Outlook, Excel), Microsoft Access
- Knowledge of current case management standards, medical practice and insurance benefit structures to negotiate medical review decisions and interpret contract benefits and managed care guidelines.
We are an Equal Employment Opportunity/Affirmative Action Employer and ADA compliant
www.carefirst.com/careers
Please apply before: 7/31/2012
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If you were eligible to this position, please email us your resume, with salary requirements and a resume to CareFirst BlueCross BlueShield.
If you interested on this position just click on the Apply button, you will be redirected to the official website
This position starts available on: Tue, 17 Jul 2012 05:20:02 GMT