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Coord, Care Management - Managed Care - Full Time

Company: Saint Joseph Health System
Location: Mishawaka
Posted on: December 3, 2019

Job Description:

JOB SUMMARY The Care Manager is responsible for the development and implementation of comprehensive effective case management services for a defined population. The Care Manager works collaboratively with the health plans, physicians and members to achieve clinical and financial outcomes, encourage the use of evidence-based guidelines in the delivery of care and ensure network compliance. Case management services are provided across the entire continuum of care. JOB DUTIES 1. Actively demonstrates the organization’s mission and core values, and conducts oneself at all times in a manner consistent with these values. 2. Knows and adheres to all laws and regulations pertaining to patient health, safety and medical information. 3. Coordinates all aspects of care, across settings and over time, including the medical community and support resources necessary to achieve optimal physical independence and quality of life. 4. Coordinates other medical services between principle care providers (who may be specialists) and the primary care physician. 5. Coordinates information sharing across the continuum. 6. Contributes to department goals and objectives in containing health care costs and maintaining a high quality medical delivery system through ensuring appropriate use of the health care system and avoidance of readmissions. 7. Ensures that complete assessment data is available for treatment planning, including risk factors, comorbidities, previous clinical history, ancillary studies, psychosocial assessment and environmental assessment. 8. Monitors on an ongoing basis patient compliance including physician appointments, therapy services, self-monitoring tools, medications and lifestyle. 9. Assists patients in maintaining an active and accountable role in the management of their diseases. 10. Discusses and/or educates the patient and family members as appropriate regarding the treatment plan. 11. Develops an individual plan of care for each patient reflecting goals, treatment plans and outcomes for each patient. 12. Collects accurate and timely health care data and adequately documents patient related issues, provider related issues and appropriate use of codes (ICD-9, DRG, HCPCS and CPT codes). 13. Works with Provider Relations by communicating office/provider concerns, needs and expectations. 14. Utilizes all sources of available patient information and secure communication methods, including fax, phone, electronic medical record, health information exchange, case/utilization management system, claims systems, data management systems, etc. Serves as a liaison for PCP/PCP office staff and health plans. 15. Maintains courteous, professional posture at all times. 16. Demonstrates behaviors consistent with identified competencies and job requirements (i.e., continuing education, mandatory in-services, safety training, annual TB testing and organizational integrity program). 17. Reviews claims and follows up on pending claims. 18. Maintains appropriate logs identified by the Medical Management department. 19. Provides health coaching services to defined population, including education regarding disease processes, prevention, positive healthy behaviors, screenings, appropriate use of health care system, education regarding health plan and benefits. 20. Assists in the development of care management programs and in the development of outcome monitoring systems and reports to measure the impact of the programs. 21. Assists in the updating of electronic case management system to enhance the care provided in the care management programs and the development of additional Select products. 22. Performs other related duties as assigned. JOB SPECIFICATIONS AND CORE COMPETENCIES Education: Bachelor of Science in Nursing or other health-related field preferred. Licensure: RN Indiana license or applicable professional license Experience: Two years of clinical experience required. Willingness to learn new software systems required. Experience in utilization management, case management, quality assurance, discharge planning or other cost management program preferred. Experience in patient education, management, and working with physicians on an individual or group basis preferred. Other Job Requirements: Coordinates and manages the care of complex patients to facilitate achievement of quality, service and cost outcomes. Works collaboratively with interdisciplinary teams, both internal and external. Work volume is high and complex, requiring excellent communication skills, with sensitivity to diverse ethnic and cultural issues. Must have a sound understanding of managed care products and benefit designs. Requires the ability to function independently including excellent organizational and time management skills. Assigned hours within your shift, starting time, or days of work are subject to change based on departmental and/or organizational needs.

Keywords: Saint Joseph Health System, Mishawaka , Coord, Care Management - Managed Care - Full Time, Other , Mishawaka, Indiana

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