[Hiring] Case Manager - Health Services @Sharp HealthCare

Role Description

This position is responsible for performing effective acute and ambulatory case management, utilization management and claims review activities, to ensure appropriate, cost-effective care to Sharp Health Plan (Plan) members, while always maintaining the highest quality of service.

Qualifications

• Graduate of an NLN-accredited School of Nursing
• 2 Years Behavioral Health and Medical Nursing experience
• California Registered Nurse (RN) - CA Board of Registered Nursing - REQUIRED

Preferred Qualifications

• Bachelor's Degree in Nursing
• 3 Years Utilization, quality, and/or case management experience in managed care setting

Essential Functions

• Authorizations:
  • Authorization of medically necessary patient care services and appropriate levels and types of services.
  • Utilize Sharp Health Plan Medical Policies in conjunction with Milliman Care Guidelines for medical necessity approvals and referrals to the Plan Medical Director.
  • Ensure all denial letters include the appropriate and individualized denial reason and alternate plan of care as determined by the Plan Medical Director.
• Care coordination and advocacy:
  • Utilization of the Nursing Process in the coordination of the delivery of health care services to a specified population of members: Assessment, Planning, Implementation and Evaluation.
  • Coordination of care between the primary physician, specialists, vendors, community services and client/caregiver including extra-contractual case by case rate negotiations.
  • In conjunction with the patient and family physician, develop a care plan for the delivery of acute or community based services.
  • The case manager will coordinate all care, negotiate service arrangements as directed by the Health Services Manager, and ensure that all caregivers and vendors are involved with the care plan.
  • Maintain detailed, accurate and timely data files on each client adhering to program guidelines.
  • Participate with the approval of Manager of Health Services in the planning / implementation of health education/quality improvement initiatives that have a case management component.
• Claims management:
  • Provide Prospective, Concurrent, Retrospective and Claims Review and Care Management services for Sharp Health Plan members who are identified as having complex health or functional requirements or are candidates for a disease management program.
  • Effective communication and screening of client, in-home assessment, care planning, arranging and coordinating services, monitoring, and consistently reassessing needs and services for members on a pre-service, concurrent and/or retrospective basis; either telephonically or onsite as needed.
• Clinical expert:
  • Ensure provider compliance with plan standards and guidelines.
  • Perform ongoing education of clients, providers, medical groups and hospitals, as applicable, regarding plan benefits and alternative resources.
  • Serve as trainer / mentor for new case managers during their first 90 days of hire.
  • Participate with the approval of Manager of Health Services in the testing of new UM and CM applications.
  • Serve as a clinical resource for customer service representatives as appropriate.
  • Promote self-awareness and knowledge of current medical standards in the community, recent innovations in patient care, and availability of alternative resources.
• Customer service:
  • Provides prompt, accurate and excellent services to internal and external customers.
  • Develops solid professional working relationships with various internal departments and units and, as required, vendors, providers, employers, brokers and/or other customers.
• General support:
  • Participates in special projects and other duties as assigned. These may include, but are not limited to, work groups, proposals, audits and back-up support for other departments.
• Reports:
  • Evaluation of health service utilization patterns to promote the continuing education of cost effect health utilization.
  • Analysis of utilization and case management statistics and organization & provision of reports.
  • Develop and maintain monthly utilization and case management reports and analysis of statistics and report conclusions to the Health Services Manager.

Knowledge, Skills, and Abilities

• Knowledge of current standards of practice and available health resources within the community.
• Demonstrated objectivity and tact in the provision of assistance to members and providers.
• Ability to recognize medically necessary care versus unnecessary or inappropriate service.
• Ability to work well on own, without supervision.
• Knowledge of a variety of health care delivery settings.
• Excellent written and verbal communication skills.
• Organizational, analytical and problem solving skills.