Global Nurse Case Manager, TriCare Overseas Program

TOP Case Management Program Manager

At International SOS, we are in the business of protecting and saving lives. For 40 years, we have delivered customised security risk management, health, and wellbeing solutions to organisations worldwide. With a presence in 90 countries and a team of nearly 13,000 experts, we provide 24/7 support to help organisations fulfil their Duty of Care responsibilities.

Now, we're looking for talented individuals to join our team and make a difference.

Case Management is a collaborative process of assessment, planning, facilitation, care coordination, evaluation and advocacy for options and services to meet an individual's and family's comprehensive health care needs through collaboration and communication regarding available resources to promote high quality, cost-effective outcomes.

The TOP Case Management Program Manager is an integral member of the TRICARE global Medical Team. The individual is responsible for managing the TOP Case Management Program to identify and support the management of the health care of individuals with high-cost conditions or with specific diseases or conditions for which evidence-based clinical management guidelines exist.

The TOP Case Management Program (CMP) is delivered by the Program Manager and their three direct reports, the Case Managers for each TOP region. This may be done telephonically and/or face to face to assess, plan, implement and coordinate all case management activities with TRICARE beneficiaries eligible for the TOP Case Management Program.

The core and critical responsibilities of the role includes:

• To work collaboratively with superiors, peers, and other individuals in the completion of duties – both internal to International SOS as well as with subcontractors, the Defense Health Agency, and the TRICARE beneficiaries we serve.
• Ensure a high level of professionalism at all times when dealing with beneficiaries, colleagues, and TRICARE.
• Ability to work within a remote team to actively drive a high level of service delivery.
• To apply medical knowledge to high cost, unusual or complex requests for medical care to determine medical necessity and appropriateness.
• Demonstrate written and oral communication skills to formulate business correspondence and convey complex medical information to other key stakeholders.
• Maintain an overview of any challenging or complaint cases and provide direction as required / requested.

Management of the TOP CMP:

• Establish, develop, standardize, and maintain quality of the TOP CMP.
• Review all referred cases from any source and provide determination regarding appropriateness of inclusion in the TOP CMP.
• The allocation of new cases to the designated case managers for engagement and case management.
• Monitor the case managers' case assignment and workload distribution.
• Hold regular meetings with the CMNs to facilitate case discussion, provide support and guidance and deliver ad hoc role specific training.
• Ensure TOP CMP cases are appropriately managed and provide case direction as required.
• Promote and reinforce the need for evidence-based medical decision making.
• For OCONUS TRICARE Prime ADSM/ADFMs enrolled to an MTF, notify the MTF that the beneficiary has a qualifying diagnosis for case management by the MTF.
• Review and document case/cost savings due to the TOP CMP.
• Work collaboratively with other business functions such as the Operations, Beneficiary Support Centre (BSC), Utilization Management, TPSS / WPS regarding identified billing and claims issues that TOP CMP beneficiaries are experiencing.

Education:

• Provide TOP CMP induction and ongoing role specific education, support, coaching and direction to the CMNs.
• Provide TOP CMP education to other key stakeholders on an ad hoc / as required basis, i.e., Operations, TPSS etc.

Client Interaction:

• Act as a subject matter expert regarding the TOP CMP
• Maintain a high level of client and procedural knowledge and ability to engage and interface with the client where appropriate.
• Participate in monthly TOP CMP case presentations to the TRICARE Area Office Medical Director/s and Nurses.
• To present and participate in semi-annual surveillance audits.
• To participate in any other client related duties as required.

Reporting:

• Tracking and trending of TRICARE beneficiaries who accept case management services, length of time on case management, diagnoses of members on case management, readmission of individuals case managed, projected cost savings resulting from case management, and other metrics as determined by contract or internal stakeholders.
• Create and maintain dashboards within the CRM case management system to support the aboveOperations
• Responsible for the tracking, trending, and reporting of TOP CMP cases and quality improvement initiatives for the annual CDRL A110 - Clinical Quality Management Program Clinical Quality Oversight Report Plan Report.
• Act as the lead, in collaboration with the TOP Data Analytics team and CQAIL for the accurate and timely submission of the CDRL M010 – Monthly Case Management Report
• Support the completion and review of the annual CDRL – P050 Case Management Program Plan.
• Assist when required with the preparation and/or presentation of other ad hoc reporting regarding the TOP CMP i.e., for semi-annual audits etc.
• Act as the subject matter expert for the creation, review, and revision of Standard Operating Procedures (SOPs) assigned to the Case Management Program.

Quality:

• Focus on quality-of-service delivery to ensure that the highest possible levels are achieved.
• Report to the TOP DoN the program progress, quality concerns and any other areas of concern and submit feedback to the International SOS customer feedback system as needed.
• Conduct internal and semi-annual surveillance audits of the TOP CMP for monitoring of performance, trend analysis, etc.
• Manage complaints in a professional manner, resolving them wherever possible or escalating them to the appropriate department.

Other Duties:

• Work within a team and promote all International SOS & TRICARE policies and procedures.
• Any other duties allocated by the TOP Director of Nursing and/or the TOP Head of Clinical Operations and Policy
• To work flexible hours as appropriate to the needs of the post.
• To recognise limitations and areas of self-development through reflection. To be responsible for all actions and decisions made, knowing when to defer or escalate to other senior members of the quality and medical teams.
• Keeps own operational technical / functional skills and knowledge up to date.
• Be responsible for own Continuing Professional Education. International SOS will endeavour to support appropriate Continuing Professional Education requests.
• Attend supervision, training, and departmental meetings as and when required.
• Undertake accountability for workload.
• To keep accurate records.

Required Skills and Knowledge (Brief description of technical knowledge or skills needed to perform the job):

• Attention to detail.
• Broad Medical Knowledge.
• Effective communication skills: Exercise's discretion and judgment when providing feedback, guidance, and clarification to ensure the relationship is protected.
• Converses fluently in English.
• Ability to provide clear and concise written updates in English.
• Identifies and acts on potential problems and / or difficulties.
• Demonstrates appropriate listening skills.
• Demonstrates effective problem-solving skills and lateral thinking.
• Able to work under pressure and to prepare accurate and timely reports in line with the requirements of the TOP.
• Working knowledge of Microsoft Office applications and the ability to learn and work with International SOS and subcontractor databases and software.
• Knowledge or familiarity with the TRICARE Overseas Program (preferred).
• Positive motivation, encouragement, and influence skills

Required Competencies (Critical behaviors necessary to successfully perform the job):

• Customer service oriented.
• Empathetic and able to positively influence the customer journey experience.
• Team player.
• Has initiative, takes responsibility.
• Ability to work independently.

Required Qualifications (Brief description of the educational background needed to perform the job):

• 3+ years clinical experience required.