Senior Case Manager - Health Coordinator, Ltss (Maui)

** Hybrid Work Environment - Must reside on Maui **

Pay Range: $81,082 - $133,352

Note: Individuals typically begin between the minimum to middle of the pay range

This position will engage members and conduct assessments and apply critical thinking and knowledge to identify health risks, developing appropriate health action plans (HAP)/Plan of Care (POC) and implementing a plan to close the gaps and reduce the risks for members in HMSA QUEST LTSS and Complex Case Management programs. Data from multiple sources will be leveraged to develop the plan of care based on working with healthcare providers, members and or authorized representative ensuring understanding of medical requirements, treatment options, health plan benefits, available resources and minimizing the fragmentation of care services and adverse outcomes.

A Case Manager/Health Coordinator (CM/HC) is an individual who is part of a multi-disciplinary team who ensures that appropriate and timely services are provided to the most vulnerable members at HMSA.

• Engagement, Assessment, and Planning
  
  • Conduct comprehensive assessment including a health and functional assessments (HFA) or initial assessment (IA) by gathering clinical information which includes past medical history, medications, physical/psychosocial factors, cultural influences, evaluation of health care barriers to include: available support systems, available benefits, community resources, financial, transportation, employment, housing, educational, and health information as appropriate to develop and create an effective HAP/POC.
  • Develop, document and implement a HAP/POC based on the assessment and information gathered.
  • Complete the state level of care 1147 form, and develop, document, and implement HAP/POC based on the assessment for members eligible for LTSS services and complex case management needs. Utilizes extensive case-management clinical knowledge and experience to coordinate integrated HAP/care-plan in collaboration with Primary Care Physician (PCP), specialists and other healthcare providers/vendors. Goals developed will be prioritized, action-oriented and time-specific to stabilize the complicated health care condition.
  • Conduct face to face visits in member's homes, facility, and/or community setting, provider offices or safe location of member's choice. Assess the home to determine functional impairments, personal care needs, skilled nursing needs, caregivers' ability to provide care, and make the determination if member has the resources to stay in their own home or needs placement in a foster home of nursing facility.
  • Executing the transition of care and facilitates review of service request containing all appropriate information (clinical, medical policy, contact/complex benefit structure, FDA treatment, clinical trials and drugs) via collaboration with Medical Management for a medical necessity determination.
  • Determines need for and conduct inter-disciplinary and/or family. conferences.

• Implementation/Evaluation
  
  • Analyze situations and determine proper course of action by making critical decisions and utilizing independent clinical judgment.
  • Proactively identifies member care needs and develops and communicates a collaborative HAP/POC. Ensures member is progressing towards desired outcomes by monitoring care through ongoing assessments and/or member records.
  • Assists with planning and coordination including out of state services.
  • Communicates with providers and develops collaborative relationships.
  • Interacts with the member as needed and necessary via telephone and face-to-face visits and provides support until the member and their authorized representative are able to self-manage and maintain the health of the member.
  • Documents the necessary communication and follow up with the member, family, physicians, and other health care providers to ensure the member's progression in meeting the established care plan goals.
  • Evaluates the extent to which the established goals in the plan of care have been achieved.

• Miscellaneous Support
  
  • Participates in required trainings and meetings.
  • Attend trainings as required by DHS and apply to day-to-day work (LTSS). Participates in meetings with Providers and Provider groups (CCM).
  • Document timely using NCQA standards/requirements and per department Desktop Procedure (DTP)/Key Work Processes (KWP).

• Performs all other miscellaneous responsibilities and duties as assigned or directed.