Complex Case Manager

Community Health Choice, Inc. (Community) is a non-profit managed care organization (MCO), licensed by the Texas Department of Insurance. Through its network of more than 10,000 providers and 94 hospitals, Community serves over 400,000 Members with the following programs: ' Medicaid State of Texas Access Reform (STAR) program for low-income children and pregnant women ' Children's Health Insurance Program (CHIP) for the children of low-income parents, which includes CHIP Perinatal benefits for unborn children of pregnant women who do not qualify for Medicaid STAR ' Health Insurance Marketplace Plans that offer individual health coverage that includes preventive care, emergency services, prescription drugs, and hospitalization available to all, regardless of pre-existing conditions. ' Community Health Choice (HMO D-SNP), a Medicare Advantage Dual Special Needs plan for people with both Medicare and Medicaid that combines Medicare Part A and Part B benefits, Medicare Part D prescription drug coverage, and Medicaid benefits with additional health benefits like dental, vision, transportation, and more. Improving Members' experiences is at the heart of every Community position. We strive every day to make sure that our Members have access to the high-quality health care they need and deserve. Community is accredited by URAC for its health plan operations. We offer care management programs for asthma, diabetes, and high-risk pregnancy. An affiliate of the Harris Health System (Harris Health), Community is financially self-sufficient and receives no financial service from Harris Health or from Harris County taxpayers. JOB SUMMARY: The Complex Case Manager (CCM) will identify, monitor, manage, and evaluate the delivery of health services to Community members with chronic, medically complex or catastrophic conditions in both acute and non-acute settings. The CCM will coordinate the care of a member with the involvement of the member, their PCP, Specialist and other provider. The CCM will identify the most medically appropriate therapeutic intervention to maximize the clinical outcomes associated with chronic medically complex diseases with potentially catastrophic outcomes. The CCM will perform a telephonic assessment and create an individualized plan of care and discharge needs assessment based on member needs utilizing available benefits and resources. The CCM will authorize services for active members admitted to the case management program at all levels of care, including outpatient, inpatient, and transitional levels of care. The CCM will help ensure proper data entry of authorization in the managed care platform, and initiate the approval process for requested services/treatments utilizing nationally recognized evidenced based clinical criteria and/or internal policys, protocols, and procedures. The CCM will use nursing knowledge, critical thinking and background to screen and review clinical information for the most appropriate service areas within Community; making referrals to community health workers, high risk perinatal and disease management teams as well as external resources. The CCM will work closely with the medical directors and refer requests that do not meet medical necessity criteria. The CCM will initiate request for single case agreements and or letters of agreement for members requiring out of network providers. The CCM will be responsible for meeting required performance and quality metrics and ensure reviews are completed within established regulatory, and state requirements. MINIMUM QUALIFICATIONS Education/Specialized Training/Licensure: Registered Nurse ( RN) , current unrestricted license in the state of Texas, BSN preferred, CCM required or must receive within 18 months of employment. Work Experience (Years and Area): 5 years clinical experience in an acute care setting preferred. At least 2 years insurance related experience in a managed care environment. Software Operated: Microsoft Office (Word, Excel, Outlook) Special Requirements: Communication Skills: Above Average Verbal (Heavy Public Contact) Other Skills: Analytical, Medical Terms, MS Word Other Requirements: Strong written and verbal communications skills. Demonstrated ability to motivate others. Use of personal car is required. #J-18808-Ljbffr