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Reporting to Manager of Care Management, the Care Manager will be an integral member of the health plan's medical management team. This position is responsible for identifying and connecting high risk members to appropriate resources and programs to achieve optimal quality and financial outcomes. Responsibilities include managing and triaging self-referrals, identifying high risk members through HRA, reporting and admissions data, auditing patient charts of delegated case management programs to meet accreditation standards, and connect members with in-network providers and resources. This position is committed to the constant pursuit of excellence in improving the health status of the community.
MINIMUM QUALIFICATIONS:
EDUCATION, CERTIFICATION, AND/OR LICENSURE:
1. Current unencumbered licensure with the WV Board of Registered Nurse Professional Nurses, or appropriate state board where services will be provided, as a Registered Nurse professional OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC)
EXPERIENCE:
1. Three (3) years of healthcare clinical experience
PREFERRED QUALIFICATIONS:
EDUCATION, CERTIFICATION, AND/OR LICENSURE:
1. Bachelor's Degree in Nursing OR Associate of Science in Nursing Degree (ASN) or Diploma; Currently enrolled in a BSN program and BSN completion within three (3) years of hire
EXPERIENCE:
1. Management of Medicare and/or Medicaid populations preferred
2. Two (2) years Care Management experience
CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.
1. Participate in activities related to care management program build, implementation, oversight, and delegation.
2. Perform utilization management reviews as needed according to accepted and established criteria, as well as other clinical guidelines and policies.
3. Manage and triage member self-referrals to care management programs.
4. Assist members in understanding their available medical benefits and connecting them with in network providers and community resources.
5. Identify barriers preventing the member from meeting maximum quality of life.
6. Review and Evaluate Health Risk Assessment (HRA) data to help drive development of programs and services geared toward member needs.
7. Review and Evaluate member outcomes data and work with other team members on performance improvement opportunities.
8. Utilizing NCQA standards in auditing processes of member records as part of care management oversight processes.
9. Investigating potential quality of care issues that may affect the quality or safety of the health of members.
10. May review medical records and other documentation to ensure quality care.
11. Assist in reviewing and updating activities and resources to address member needs.
12. Participate in case management and quality committees.
13. Assist in reviewing and updating policies and procedures to align with delegated processes.
14. Assist in quarterly reporting of delegated case management processes to meet accreditation standards.
15. Assist in submission of required documents/policies during application process to accrediting body.
WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
1. Standard office environment
SKILLS AND ABILITIES:
Working Knowledge of InterQual and/or Milliman Care Guidelines
Demonstrated knowledge of federal and state laws, NCQA and industry regulations related to disease management, utilization management, care management and discharge planning
Excellent written and oral communication
Problem solving capabilities to drive improved efficiencies and customer satisfaction
Attention to detail
Proficiency with Microsoft Office
Additional Job Description:
Scheduled Weekly Hours:
40
Shift:
Day (United States of America)
Exempt/Non-Exempt:
United States of America (Exempt)
Company:
PHH Peak Health Holdings
Cost Center:
2403 PHH Medical Management
Address:
1085 Van Voorhis Rd
Morgantown
West Virginia
Reporting to Manager of Care Management, the Care Manager will be an integral member of the health plan's medical management team. This position is responsible for identifying and connecting high risk members to appropriate resources and programs to achieve optimal quality and financial outcomes. Responsibilities include managing and triaging self-referrals, identifying high risk members through HRA, reporting and admissions data, auditing patient charts of delegated case management programs to meet accreditation standards, and connect members with in-network providers and resources. This position is committed to the constant pursuit of excellence in improving the health status of the community.
MINIMUM QUALIFICATIONS:
EDUCATION, CERTIFICATION, AND/OR LICENSURE:
1. Current unencumbered licensure with the WV Board of Registered Nurse Professional Nurses, or appropriate state board where services will be provided, as a Registered Nurse professional OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC)
EXPERIENCE:
1. Three (3) years of healthcare clinical experience
PREFERRED QUALIFICATIONS:
EDUCATION, CERTIFICATION, AND/OR LICENSURE:
1. Bachelor's Degree in Nursing OR Associate of Science in Nursing Degree (ASN) or Diploma; Currently enrolled in a BSN program and BSN completion within three (3) years of hire
EXPERIENCE:
1. Management of Medicare and/or Medicaid populations preferred
2. Two (2) years Care Management experience
CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.
1. Participate in activities related to care management program build, implementation, oversight, and delegation.
2. Perform utilization management reviews as needed according to accepted and established criteria, as well as other clinical guidelines and policies.
3. Manage and triage member self-referrals to care management programs.
4. Assist members in understanding their available medical benefits and connecting them with in network providers and community resources.
5. Identify barriers preventing the member from meeting maximum quality of life.
6. Review and Evaluate Health Risk Assessment (HRA) data to help drive development of programs and services geared toward member needs.
7. Review and Evaluate member outcomes data and work with other team members on performance improvement opportunities.
8. Utilizing NCQA standards in auditing processes of member records as part of care management oversight processes.
9. Investigating potential quality of care issues that may affect the quality or safety of the health of members.
10. May review medical records and other documentation to ensure quality care.
11. Assist in reviewing and updating activities and resources to address member needs.
12. Participate in case management and quality committees.
13. Assist in reviewing and updating policies and procedures to align with delegated processes.
14. Assist in quarterly reporting of delegated case management processes to meet accreditation standards.
15. Assist in submission of required documents/policies during application process to accrediting body.
WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
1. Standard office environment
SKILLS AND ABILITIES:
Working Knowledge of InterQual and/or Milliman Care Guidelines
Demonstrated knowledge of federal and state laws, NCQA and industry regulations related to disease management, utilization management, care management and discharge planning
Excellent written and oral communication
Problem solving capabilities to drive improved efficiencies and customer satisfaction
Attention to detail
Proficiency with Microsoft Office
Additional Job Description:
Scheduled Weekly Hours:
40
Shift:
Day (United States of America)
Exempt/Non-Exempt:
United States of America (Exempt)
Company:
PHH Peak Health Holdings
Cost Center:
2403 PHH Medical Management
Address:
1085 Van Voorhis Rd
Morgantown
West Virginia
