Case Manager - Disease Management

•Educate and engage members in participating in a disease management program regarding living a healthy lifestyle.
•Must be able to solve problems while exhibiting clinical judgment and realistic understanding of the current environment.
•Must be able to make independent decisions about appropriateness, resource utilization, and quality of care without supervisory assistance except in unusual circumstances.
•Must demonstrate understanding of clinical and psychosocial issues that may alter treatment or care plan and be able to demonstrate good judgment when dealing with emotionally charged situations.

CUSTOMERS & THEIR NEEDS

Primary: Program/Process Leader and other clinical case managers and support staff.

Secondary: Medical Director, Director of Health Resource Management, Senior Manager Case and Disease Management, other PC departments, providers.

MEASURES OF SUCCESS

•Provision of individual disease/case management leading to quality outcomes (while shifting care from inpatient settings to ambulatory settings, as demonstrated by reduced utilization of services and avoided repeat admissions.

•Objective improvement in provider/patient program satisfaction scores as demonstrated by trend data.

•Maintains a caseload/documentation according to company standard size.

REQUIRED COMPETENCIES

Leadership: The Disease/Case manager must demonstrate the ability to be able to collaborate, coordinate, assess, plan, implement, and evaluate options or services to meet an individual's health care needs. This will be done through communication and available resources to promote quality cost effective outcomes.

Clinical Judgment: Must demonstrate proficiency in clinical judgment in order to anticipate issues expected as the result of disease progression, complication or illness resolution. Well developed patient education skills. Able to make clinical judgment based on verbal cues, due to telephonic limitations.

Problem Solving: Can overcome the restrictions of telephonic interventions. Analyzes and understands why problems occur; looks beyond the obvious and identifies subtle relationships among important factors. Generates creative yet effective solutions considering organizational obstacles. Documents solutions so they are clearly understood by others. Models how problems should be solved.

Flexibility: Able to adapt and work effectively with a variety of situations, individuals or groups. Able to understand and appreciate different and opposing perspectives on an issue; to adapt an approach as the requirements of a situation change, and to change or easily accept changes in one’s own organization or job requirements. Demonstrates the ability to tolerate ambiguity.

Customer focus: Must develop and maintain an effective working relationship with the patient, family/caregivers, the physicians, providers attending the member, community resources and internal plan staff. Should be accomplished through open, honest and timely customer-focused communication.

Written Communication: Able to write clearly and effectively, present ideas and to document activities; able to read and interpret written information.
REQUIREMENTS
Minimum Education/
Experience:
•Bachelor's degree in Nursing, New York State RN Licensure required.
•Three (3) years clinical experience working with individuals in ambulatory, acute or home care settings. Cardiac/Diabetes/Respiratory experience required.
•Patient teaching experience required.
•Community Health experience preferred
•Case and utilization management experience preferred.

OR

•Associates Degree in Nursing, New York State RN licensure required
•Five (5) years experience working with individuals in ambulatory, acute or home care settings. Cardiac/Diabetes/Respiratory experience required.
•Patient teaching experience required.
•Community Health experience preferred.
Case and utilization management experience preferred.

Licenses/Certifications:
Current New York State RN licensure

Required Skills:
Independent and creative problem solving

Decisiveness
Goal-setting
Excellent oral and written communication
Negotiation
Organization and Time Management
Excellent customer service
Knowledge of UM systems policies and workflows
Knowledge of alternate level of care options and the ability to move the member successfully through the continuum of care
Strong knowledge of community resources

Computer Skills:
Basic Word and Excel competency required; intermediate level preferred. (will need to have ability to produce documentation, organize and save files, produce databases, graphs)

Working Conditions:
Traditional office environment

Travel required within Preferred Care's service area (must have and maintain access to a vehicle and possession of a valid NYS driver's license).

Valid New York State driver's license and access to a vehicle

Certified Case Manager Certification (CCM) required within 24 months after hire.