Job Title: Complex Case Mgr
Posting Location: VA - Bristol
Location: VA - Bristol
Employment Status: Full Time
Job Requisition Number: 172238
External Description:
Coventry Health Care - Southern Health, a leader in the managed care industry,
has an opening for a Nurse Case Manager in the Bristol area. This individual
will function as the central coordinator of care for members/injured employees
identified as having chronic disease processes or for members/injured employees
in select physician practices. Responsible for implementing and coordinating all
case management activities relating to catastrophic cases and chronically ill
members/injured employees across the continuum of care including consultant
referrals, home care visits, use of community resources, and alternative levels
of care. May be responsible for developing and executing implementation plans
with a physician practice to coordinate all case management activities. Uses
computer-based systems to review medical experience of members/injured employees
and interact with staff. This position may specialize within a disease area.
ESSENTIAL RESPONSIBILITIES
- Responsible for the comprehensive management of members/injured employees with
a catastrophic illness or for members/injured employees in select physician
practices.
- Responsible for the proactive management of chronically ill members/injured
employees with the objective of improving quality outcomes and decreasing costs.
- Responsible for the early identification and assessment of members/injured
employees for admittance to a comprehensive case management program.
- Applies case management concepts, principles, and strategies in the
development of an individualized case plan that addresses the member's/injured
employee's broad spectrum of needs. The case planning process includes the
following actions: assessment, goal setting, establishing interventions related
to goals, monitoring success of the interventions, evaluating the success of the
overall case plan, and reporting outcomes.
- Interviews members telephonically, in their home, physician office or in other
facilities to provide initial and ongoing case management services.
- Conducts regular discussions and updates with the member's primary care
physicians, other providers including behavioral health providers, health plan
Medical Directors, health services staff, or the injured employee's insurance
company and employer regarding the status of a particular member/injured
employee.
- Serves as the member/injured employee's advocate to ensure they receive all
necessary care allowed under their benefit plan. Develops knowledge of community
resources and alternate funding arrangements available to the member/injured
employee when services are not available under their benefits program.
- Develops new programs as appropriate to reduce admissions for acute and
chronic members/injured employees and assist with decreasing their lengths of
stay.
- Develops relationships with hospital social workers and community resources to
assure appropriate management of catastrophic and chronically ill
members/injured employees.
- Develops an understanding of healthcare reimbursement methods that promotes
the provision of cost effective healthcare and the preservation of the
member/injured employee benefits.
- Assists in the identification and reporting of potential quality improvement
issues. Responsible for assuring these issues are reported to the Quality
Improvement Department.
- May serve as a consultant to the physician network(s) to insure overall
improvement in quality of medical care and outcomes.
- May serve as liaison and key resource for Appeals Coordinators for cases
involving utilization management, case management, and general medical issues.
- May be responsible for handling sensitive appeal cases that involve complex
medical issues assuring all regulatory requirements are met. Works closely with
senior management and the Legal Department on these cases. May work with
worker's compensation defense and plaintiff attorneys and testify as required.
- May be responsible for comprehensive management of appeal cases for
members/injured employees involving transplants.
- Maintains confidentiality of member's/injured employee's information in
accordance with HIPAA regulations.
- Performs other duties as required.
JOB SPECIFICATIONS
- Registered nurse with active state license.
- Bachelor's degree or equivalent experience preferred.
- Complies with all state certification requirements in the state where job
duties are performed.
- Previous experience (usually 1+ year) in case management.
- Significant experience (usually 3+ years) clinical experience.
- If required by URAC/NCQA accreditation, or the health plan, case management
certification must be obtained within 4 years of date of hire.
- Utilization management experience and knowledge of community resources
preferred.
- Experience with using computer systems as part of the clinical activity.
- Regular local travel may be required.
Coventry Health Care is an Affirmative Action/Equal Opportunity Employer, and we
are committed to building a talented and diverse team. CBC:05/04/2012
Nearest Major Market: Virginia
Job Segments: Behavioral Health, Case Manager, Healthcare, Home Care, Law, Legal, Managed Healthcare, Management, Manager, Medical, Nursing, Registered Nurse
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