The Dean Health Plan Case Manager is responsible for managing members who have been identified as appropriate for Dean Health Plan (DHP) case and disease management programs in a telephonic setting and/or at the point of care. The DHP Case Manager serves in an expanded nursing role to collaborate with members and their Primary Care Providers to ensure the delivery of quality, efficient, and cost-effective healthcare services for the DHP member population.
The Case Manager assumes an active role within the interdisciplinary team to achieve optimal clinical and resource outcomes. The Case Manager is responsible for assessing, planning, implementing, coordinating, monitoring and evaluating care plans, services and outcomes to maximize the health of members. This position provides assessment of the appropriate disease state and assesses the health care and educational needs of the members.
Essential Job Duties:
Responsible for managing members in case and disease management programs via telephone and/or at the point of care.
Assesses identified members and completes a comprehensive assessment. Develops a care plan utilizing clinical expertise to identify and evaluate the members need for additional medical services, modifiable risk factors and educational needs, and identifies or refers cases for other services. Assesses short-term and long-term needs; prioritizes member-directed goals and interventions that will have the greatest impact on the member's overall health; assesses barriers to attainment of prioritized goals; and revises the member's care plan as appropriate. Maintains required documentation for case management activities.
Communicates with PCP/Providers and the healthcare team regarding member needs
Collaborates with other Case Managers on cases to review care plans and make changes if necessary
Acts as a liaison and member advocate between the member and their family, physician and facilities/agencies
Interacts continuously with member, family, physician(s), and other providers utilizing clinical knowledge and expertise to determine medical history and current status.
Applies accepted clinical criteria and guidelines to ensure appropriate administration of benefits and optimum medical outcomes.
Authorizes and coordinates required services in accordance with the benefit plan and works collaboratively with the Utilization Management Department for prior authorization requirements.
Assesses options for care including use of benefits and community resources to update the care plan as needed.
Determines medical necessity relating to incoming correspondence and internal referrals.
Intervenes to positively affect healthcare outcomes with emphasis on member's self-management of their disease state.
Actively assists in developing program workflows to ensure smooth transitions of care for the members.
Actively assists in developing lists of medical supplies and community resources available to members and maintains collegial relationships with the entities used most frequently.
Takes a leadership role in the facilitation of department functions including mentoring staff and ensuring policies and procedures are followed.
Actively assists in the development and implementation of policies, protocols, standing orders and quality assurance standards.
Facilitates collaboration with PCP, clinics, facilities, primary care team, consulting physicians, community resources and the DHP Utilization Management Department.
Develops effective support therapies for members with complex cases and their families
Maintains HIPAA standards and confidentiality of protected health information.
Ensures compliance with all state and federal regulations and guidelines in day-to-day activities.
Assist and participate in meeting company and department goals such as quality improvement activities
Promotes timely and effective communication based on individual and/or situational requirements and utilizes appropriate means to ensure adequate information flow
Acts as a resource to the Care Management and medical Affairs Division Staff; works collaboratively and supports the efforts of team members in an office or clinic setting.
Actively supports compliance with NCQA and governmental requirements as appropriate to the position.
Performs other duties as assigned in an emergency or other operational situation for which the employee is qualified.
Registered Nurse with an unrestricted license to practice within the State of Wisconsin or eligible for unrestricted licensure in Wisconsin; maintaining active, unrestricted professional licensure is a condition of continued employment
Three to five years clinical acute experience in varied health care settings Current case management certification or other applicable certifications or willingness to obtain certification after two years of employment
Ability to work independently, handle multiple assignments and prioritize workload
Ability to exercise independent and sound judgment in decision making, utilizing all relevant information
Demonstrates high level time management, organizational skills and priority setting
Communicates effectively in person and by phone or in a community setting
Advanced ability as a licensed professional to communicate on any level required to meet the demands of the position using lines of authority appropriately.
Ability to create, review and interpret treatment plans.
Demonstrates negotiation skills
Demonstrates effective communication methods and skills,
Complies with CMSA Standards of Case Management Practice and Code of Professional Conduc
One to three years of Case Management/Disease Management experience preferred.
Bachelor's Degree in nursing preferred.
Electronic Medical Record Experience (EPIC)
Ability to facilitate and lead meetings
Previous experience with motivational interviewing of members
Experience with varied client populations (e.g. complex medical, social and economic
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