Outpatient Case Manager

Job Description

Job Description

JOB DESCRIPTIONPOSITION INFORMATION

Job Title: Outpatient Case Manager
FLSA Status: Non-Exempt
Department: Clinical Services
Reports To: Case Management Program Manager

JOB SUMMARY

Under the supervision of the Case Management Program Manager, the Outpatient Case Manager is responsible for intake and providing case management services to members with chronic medical conditions and/or socioeconomic and mental health comorbidities.

The Outpatient Case Manager assists members in achieving optimal health outcomes and/or independence in self-managing their care. Familiarity with MCG and Medicare guidelines is required.

ESSENTIAL JOB FUNCTIONS

1. Conducts health risk assessments, including but not limited to physical, functional, social, psychological, environmental, learning, and financial needs of the member.

2. Identifies problems, goals, and interventions to meet the member’s needs, including prioritized goals identified by the member and caregiver.

3. Creates individualized care plans with the member, caregiver, and member’s Primary Care Provider (PCP), including short- and long-term goals and interventions.

4. Provides appropriate interventions that demonstrate knowledge and sensitivity toward cultural diversity, religious and developmental considerations, health literacy, and educational backgrounds of the population served. Utilizes interpreter services as needed.

5. Evaluates the member’s progress toward goal achievement, including identification and evaluation of barriers to meeting the member’s needs. Reassesses for changes in goals and/or health status.

6. Conducts Interdisciplinary Care Team (ICT) meetings and communicates with the PCP and members of the interdisciplinary care team regarding the care plan and the member’s status.

7. Demonstrates knowledge and experience in managing and evaluating Health Risk Assessment (HRA) cases.

8. Acts as a member advocate and assists with problem-solving and addressing barriers to care.

9. Coordinates and refers members to appropriate community resources and facilitates access and communication when multiple services are involved.

10. Documents assessments and care plans in the Care Management System.

11. Adheres to payroll policies and properly utilizes the timekeeping system with minimal manual changes.

12. Maintains regular and consistent attendance.

13. Adheres to the Compliance Plan and HIPAA regulations.

MARGINAL JOB FUNCTIONS

1. Takes on special projects as needed.

2. Performs other duties as assigned.

BEHAVIORAL EXPECTATIONS1. Continuous Learning

a. Attends staff meetings as required.

b. Attends appropriate training, seminars, and workshops as required.

2. Customer Focus

a. Maintains client/customer confidentiality and privacy in accordance with HIPAA regulations and IMAS’s Standards of Conduct.

b. Fosters appropriate communication and professional relationships with supervisors, co-workers, and other staff.

3. Quality / Process Improvement / Safety

a. Reports issues of security, health, and/or safety to the appropriate supervisor as soon as practicable.

b. Supports and demonstrates safety throughout all duties performed.

c. Follows established policies and procedures and understands and complies with all regulatory standards set forth by governing entities.

POSITION REQUIREMENTSEDUCATION / EXPERIENCE

• Minimum of 2 years of nursing experience in an acute care hospital setting.

• Minimum of 1 year of managed care and utilization review experience.

• Experience with CMS and MCG guidelines.

• Experience with clinical review.

• Clinical knowledge of chronic conditions, such as diabetes and congestive heart failure.

• Strong written and verbal communication skills with patients, physicians, and other stakeholders.

• Demonstrated ability to assess and respond to patient and family needs in a timely manner.

• General knowledge of case management practices, including familiarity with relevant products and services.

• Basic computer skills, including working knowledge of the Microsoft Office Suite (Excel, Outlook, PowerPoint, and Word).

• Experience establishing professional and collaborative relationships with patients, physicians, and insurance providers.

• Experience in managed care.

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