Gateway Health Plan
Job Description :
This job assures that members with complex medical and/or psychosocial needs have access to high quality, cost-effective health care. Assists in the holistic assessment, planning, arranging, coordinating, monitoring, evaluation of outcomes and activities necessary to facilitate member access to healthcare services. Advocates for the most appropriate care plan using sound clinical judgment; accurate planning, and collaboration with internal and/or external customers and contacts. Follows established regulatory guidelines, policies, and procedures in relation to member interventions and documentation of activities related to the member’s care and progress across the continuum of care. Facilitates and/or participates in interdisciplinary and/or inter-agency meetings, when necessary, to facilitate coordination of services/resources for members. In addition to these duties, an embedded case manager works primarily out of a PCP office to meet our members face to face.
Communicate effectively. This position displays effective communication skills while performing the following functions:
- Reports daily to an assigned PCP office where they will have face to face opportunity with our members
- Face to face and telephonic case management services
- Face to face communication with PCP office staff/providers/medical team
- Interaction with internal departments such as: case management, UM department, physician advisors, management team
- Collaboration with other specialist offices, community agencies, community resources
Knowledge of Medical Terminology and Medical Diagnostic Categories/Disease States:
- Expected to educate members in order to enhance member understanding of illness/disease impact and to positively impact member care, plan adherence, pharmacy regimen maintenance, and health outcomes.
- Collaborate face to face with primary care physicians. In addition collaborate with other specialists, home health and other ancillary healthcare providers with the goal being to coordinate member care.
- Collect member medical information from a variety of sources including their assigned PCP EMR and internal records and use appropriate clinical judgement, consultation with internal physician advisors and other internal cross-departmental consultation to determine unmet member needs.
- Expected to work primarily out of their assigned PCP office and be able to work independently to identify, define, and resolve a myriad of problem types experienced by the member.
- Work collaboratively with the PCP office staff/providers/medical team daily to target members in need of case management.
- Expected to develop an individualized plan of care designed to meet the specific needs of each member
- Attend medical rounds/daily huddles at their office to troubleshoot the members needs and develop solutions
- Have support from their management team as well as the other embedded case managers
Maintain a working knowledge of available resources for addressing identified member needs and to facilitate proactive and efficient provision of services.
- Be knowledgeable of and consider benefit design and cost benefit analysis wen planning a course of intervention in order to develop a realistic plan of care
- Communication and collaboration with other payers (when applicable) to create a collaborative approach to care management and benefit coordination.
- Maintain a working knowledge of available community resources available to assist members. The embedded case manager will coordinate with community organizations/agencies for purpose of identifying additional resources for which the MCO is not responsible.
Work within a team environment
- Attend and participate in required meetings, including staff meetings, internal rounds, and other in-services in order to enhance your professional knowledge and competency for overall management of members.
- Participation in departmental and/or organizational work and quality initiative teams
- Case collaboration with peers, management team, physician advisors and other interdepartmental contacts
- Participate in medical rounds, interdisciplinary team meetings at your assigned PCP office to strength the collaboration and partnership
- Foster effective work relationships through conflict resolution and constructive feedback skills
- Attend internal and external continuing education forums annually to enhance overall clinical skills and maintain professional licensure, if applicable.
- Educate health team colleagues of the role and responsibility of embedded case management and the unique needs of the populations served in order to foster constructive and collaborative solutions to meet member’s needs.
Other duties as assigned or requested.
- HS Diploma with an RN License OR
- Bachelor’s Degree in Nursing OR
- Master’s Degree in Social Work
- 3 years of experience in Acute or Managed Care, with Medicaid or Medicare populations
- 5 years of experience in Acute or Managed Care, with Medicaid or Medicare populations
- Experience working with children, adults, and/or medically complex patients
LICENSES or CERTIFICATIONS
- Licensed Social Worker
- Case Management Certification
- Written & Oral Presentation Skills
Language (Other than English):
PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
Referral Bonus: Level 1
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