Care Management Specialist II

BASIC FUNCTION :
This position is responsible for discharge care coordination, episodic case management and pre-admission/post-discharge counseling for an acute condition. This position is responsible for handling duties in an independent manner and may assist other staff. Establish relationship with the member through the immediate post discharge follow-up period or until all short term care needs are met. Provide education/local resource information and encourage member (self) education. Determine case complexity and refer to other internal departments as needed.



ESSENTIAL FUNCTIONS:
1. Discharge care coordination, episodic case management and pre-admission/post discharge counseling and identification of alternate treatment options. Consult with physicians, coordinators, and facility discharge planners to determine other resources and appropriate disposition of such cases. Provide education, counseling and referral to other resources to minimize re-admissions and emergency room episodes.
2. Perform additional ongoing functions to support the member in the transition of care process including more than one of the following:
a. Consult with physicians, providers, members, and other resources, as appropriate, to assess, plan, facilitate implementation, coordinate, monitor and evaluate options and services required to meet an individual's acute health needs, using communication and available resources to promote quality health outcomes
.b. Personalize outreach/engagement based upon attitudes/behaviors/risk assessment. Outreach to provider to coordinate the member's care or to notify of risks/new conditions.
c. Reconcile, educate and monitor adherence to medication safety.
d. Reinforce provider post-operative instructions for care, diet, activity level etc.
e. Address barriers to keeping follow-up appointments with appropriate provider and assistance with appointment scheduling
.f. Assistance finding a primary or specialist provider, a Blue Distinction Center or any needed coordination with Customer Service.
g. Assist with getting to a provider if needed when all other options have been exhausted.
h. Referral to other BCC programs, or external resource community-based organizations, transportation, home health etc.
i. Provide onsite face to face intervention in select cases.
j. Education and recommendations to resolve conditions and risks, and support for behavior change/ self-management.
k. Collaborate with the provider and member when appropriate to develop alternate plans of care if needed.
l. Assist members/providers to navigate the health care system.
m. Assess cases for quality-of-care issues and refer cases to the QA/QI department for review and follow up.
n. Perform Transition of Care services for all assigned lines of business.
o. Determine case complexity and may refer to Case Management/Disease Management/Enterprise Life Style Management department personnel as necessary.
3. Practice within the scope of licensure.
4. Participate as preceptor for orientation of new employees.
5. Maintain licensure and maintain and enhance knowledge for designated area of licensure and regulatory standards by attending seminars, training sessions, etc.
6. Communicate and interact effectively and professionally with co-workers, management, customers, etc.
7. Comply with HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies and other applicable corporate and departmental policies.
8. Maintain complete confidentiality of company business
.9. Maintain communication with management regarding development within areas of assigned responsibilities and perform special projects as required or requested.



JOB REQUIREMENTS:

• Licensed Clinical Professional Counselor (LCPC) or Licensed Master Social Worker (LMSW) with current, active, unrestricted license in the state of operations (or reciprocity if applicable).
• 2 years clinical experience.
• 1 year health insurance/managed care experience.? Knowledge of medical management policies and procedures.
• PC and database experience.
• Verbal and written communication skills.
• Customer service skills and interpersonal skills to discuss pre/post admission care with physicians, hospital staff and members.
• Ability and willingness to occasionally travel within assigned location. Possess transportation and current, valid driver's license for applicable state.
• Incumbents with nursing licenses in positions/departments requiring multi-state licenses are required to obtain and maintain additional current, valid, and unrestricted applicable nursing licenses in other states as determined by management.