Case Managers are responsible for providing Case Management services to plan members to promote cost effective, high quality care.
ESSENTIAL DUTIES AND RESPONSIBILITIES
Case Managers shall be responsible for all phases of Care Management, but shall be primarily focused on:
A. Assessment: Once appropriate cases have been identified Case Managers shall be responsible for contacting patients to explain Case Management and the associated process. Case Managers shall determine individual needs based on factors such as Medical Condition, Psychological Condition, work history and situation, any payer complications, external resources. Additional pertinent factors shall also be considered.
B. Plan Development: Once assessment has been completed the Case Manager shall develop a plan that coordinates the appropriate treatment considering the facts of the assessment. The Case Manager shall provide the plan member with data to make informed decisions, and should suggest alternative forms of treatment or contingencies where possible. The Case Manager will facilitate communication between the member and the care team, and obtain approval from all parties whenever possible (member, family, providers, and payers). The plan should consider both maximize benefit to the member, while keeping cost as minimal as possible.
C. Implementation: Once the plan has been approved by the member, the Case Manager should act as liaison between all parties. The primary goal is providing excellent care based on the decided upon plan to ensure that the desired outcome is reached.
D. Evaluation of the Plan: Constant re-evaluation is required to ensure the plan is performing as designed, and to the expectations of all parties. The Case Manager shall continuously re-assess the plan and suggest changes where necessary.
Case Managers shall also assist in Identification and Selection, and Termination of the Case Management process as able in cooperation with Claim Analysts.
Qualifications: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Education and/or Experience: Bachelor’s Degree. Five or more years Clinical Nursing Experience including psychiatric/substance abuse experience, UM or Case Management Certification, Current/Active - Unrestricted Nursing License(and ability/willingness) to get multiple state licenses) or, equivalent combination of education and experience.
Language Skills: Ability to read and interpret documents such as safety rules, operating and maintenance instructions and procedure manuals. Ability to accurately write routine reports, and correspondence. Ability to speak effectively before groups of customers or employees of the organization.
Mathematical Skills: Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.
Reasoning Ability: Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Ability to deal with problems involving several concrete variables in standardized situations.
Computer Skills: To perform this job successfully, an individual should have knowledge of Internet software and the Microsoft Office Suite of products. Knowledge of basic office equipment should include: Internet and email, copy and fax machines, postage meter and telephone.
Other Qualifications: Current Nursing License (RN) and, ability and willingness to get multiple state licenses, knowledge of the medical insurance industry, medical terminology, system hierarchies, medical care and treatment, and claims processing.
Physical and Emotional Demands: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The inability to cope with a stressful work environment does not constitute a protected disability.
While performing the duties of this job, the employee is frequently required to sit. The employee is regularly required to stand; walk; use hands to finger, handle, or feel; reach with hands and arms; climb or balance; and talk or hear. The employee must occasionally lift and/or move up to10 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.
Work Environment: The work environment characteristics described here are representative of those an employee may encounter while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
The noise level in the work environment is usually quiet.
Equal Employment Opportunity Policy Statement
Lucent Health Solutions, Inc. is an Equal Opportunity Employer that does not discriminate based on actual or perceived race, creed, color, religion, alienage or national origin, ancestry, citizenship status, age, disability or handicap, sex, marital status, veteran status, sexual orientation, genetic information, gender identity, gender expression, transgender status, arrest record, or any other characteristic protected by applicable federal, state or local laws. Our management team is dedicated to this policy with respect to recruitment, hiring, placement, promotion, transfer, training, compensation, benefits, employee activities and general treatment during employment.
Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.