Case Manager

Note
This classification includes two levels of competence. The distinction between the two levels derives chiefly from, competence, credentials and complexities of assignment. Normally, a newly hired/transferred employee with limited experience but adequate formal training would be employed at level I. As the employee acquires competence to the full requirements of the position, he/she could be promoted to the second level.

Summary
Conducts case management program activities (including the Case Management process and quality improvement) in accordance with departmental, corporate, state, federal, CMSA and URAC accreditation standards, as well as CMS standards if appropriate to the case assignment. Uses a systematic approach to identify members meeting program criteria, assessing opportunities to coordinate care and treatment options, and collaborating with primary providers. Implements the Case Management process to facilitate quality, cost effective medical and benefits management.

Essential Responsibilities/Accountabilities
- Maintains knowledge of current CMSA Standards, Case Management Program activities, and performs the activities as directed by departmental policy and leadership, current Department of Health regulations/benefits for Managed Medicaid and Family Health Plus programs, and current CMS regulations and standards if managing members of Medicare programs

- Carries out job responsibilities in accordance with departmental, corporate, state, federal and URAC accreditation standards, as well as within the scope of practice and licensure as outlined in the New York State Nurse Practice Act, Article 139. Maintains confidentiality and conducts information management procedures per corporate and departmental policy.

- Implements the Case Management Process per department policies, procedures and guidelines. Facilitates quality, cost effective medical and benefits management. The process includes case identification, case opening, member assessment, developing care plans, conducting interventions, measuring member outcomes during re-assessment, case closure, and case reviews.
- Screens members that fall within the defined populations served, referred to the department, either by data analysis (i.e. high-dollar or frequent inpatient trigger reports) or by internal or external referral sources. Applies case management criteria and professional clinical judgement to determine a member’s appropriateness for case management services. Investigates members that are appropriate.
- Initiates the case manager’s role, as outlined in the Case Management Program Description, while providing case management services to members. Opens appropriate cases timely and effectively. Assures essential information that relates to case management is disclosed to members, thus increasing the opportunity for success of member outcomes.
- Works in collaboration with members’ physicians and other health care providers to assess the needs of the member, facilitate development of an interdisciplinary plan of care, coordinates services, evaluates effectiveness of services and modifies the member plan of care as necessary. Maintains positive working relationships within this arena.
- Provides appropriate resources and assistance to members with regards to managing their health care across the continuum of care. Maintains updated information related to appropriate community resources and serves as an information source for providers and other members of the health care team, and as a liaison between such providers and the community resources staffs.
- Participates in interdepartmental coordination and communication to ensure delivery of consistent and quality health care services. Examples: Utilization Management, Quality Management, and Disease Management.
- Accepts responsibility for continuing education relative to professional growth. Meets or exceeds the minimum continuing education requirements as set forth by departmental and corporate policy, and by individual professional certification standards, if applicable.
- Conducts case management statistics, cost effectiveness, and reinsurance reporting. Accurately tracks and reports time usage related to cases managed for contracted services, to ensure accurate invoices are generated for reimbursement of such services.
- Participates as a non-voting member of the Case Management Quality Assurance Committee (CM-QAC) by attending meetings, making recommendations and conducting quality activities as directed by the CM-QAC. Examples of quality activities are policy/procedure/guidelines review and development, case reviews, data collection and analysis related to current quality indicators, and encouraging member response to satisfaction surveys. Serves as a voting member if appointed as such by the CM-QAC Chair.
- Participates in and promotes Disease Management Programs, performing liaison activities with the provider network as directed by department leadership.
- Participates in the education and in-services to network providers, support staff and members as part of the plan of care or program development.
- When necessary, case managers are responsible for monitoring the activity of the Case Management Life Enrichment Specialist that affects the case management process and outcomes. Continuous collaboration is necessary to assure continuity and coordination of care.
- Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values and adhering to the Corporate Code of Conduct.
- Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
- Regular and reliable attendance is required
- Perform other duties as assigned by management.
REQUIREMENTS
Minimum Qualifications

- RN with current New York State license, BSN Preferred. CCM desired (CCM certification required after 2 years of employment as a case manager).
- Minimum of 3 years progressive clinical experience including, community health, behavioral health, and managed care experience preferred.
- Excellent written and verbal communication skills.
- Computer experience and use of measurement/criteria.
- Strong interpersonal skills.
- Must have the ability to travel.


Physical Requirements


In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.

Equal Opportunity Employer