Plan Case Manager

Plan Case Manager

This position is primarily remote with limited in home visits. Responsible for the oversight of clinical care management of community based long-term care population for PruittHealth Premier Dual Eligible Special Needs Plan (DSNP). Works to advise and coordinate clinical care across the health care continuum of both community based clinical providers as well as social support programs where PruittHealth Members receive support. Assist patients to achieve optimal health status utilizing the most cost-effective quality resources through application of model of care practice guidelines and Case Management (CM) Standards of Practice. Implement appropriate interventions to manage multiple physical, psychological, social and financial barriers in cooperation with the patient, PruittHealth Premier, and medical provider. Position will interact with members in both a home and community-based provider setting. This position is primarily remote with limited in home visits.

Duties may include, but not limited to the following:

• Conduct in-home and telephonic assessment and data collection with patients and caregivers and document findings in a concise/comprehensive manner
• Develop a case management care plan for each patient based on a thorough history and clinical record review, including the attending physician's plan, the recommendations of national guidelines, social supports in place, and in consideration of the patient's ability to comply.
• Monitor the needs of patients and families on an ongoing basis while facilitating any adjustments to the plan of care as changes are needed.
• Provide care management and coordination to assure that the patient progresses through the continuum of care and utilizes the most clinically appropriate and cost- effective quality resources through the application of national practice guidelines and CM Standards of Practice.
• Coordinate with the Plan Care Navigator/Member Advocate for the integration of the social service/support function into patient care.
• Coordinate the hospital activities concerned with case management and discharge planning.
• Helps to assure that the patient has access to a range of choices, coordination of primary care provider (PCP) and specialists, understanding of treatment plan and medications, identification of special needs and referrals, and coordination of transition between care settings.
• Educates the patient and provides emotional support on an ongoing basis related to identified risk factors and a wide variety of topics and empowers the patient to take an active role in his/her care
• Working with pharmacist and patient/caregiver to ensure medication therapy management and compliance
• Implementation of case management interventions by the application of methods, techniques, behaviors, information and learning aids that positively impact the patient and their condition.
• Function as an effective liaison between patient, PruittHealth Premier, caregivers, and other community health providers to ensure appropriate clinical oversight and engagement is provided
• Responsible for ensuring the scheduling, coordination and completion of the inter-disciplinary team with primary care provider and can also include other members such as social workers, dieticians, pharmacologist, and physician consultants, and other providers as appropriate.
• Organize, secure, integrate and modify the resources necessary to accomplish the goals outlined in the case management plan, utilizing partnership with the other plan staff where appropriate and needed.
• Timely creation of quality case management reports documenting results of CM plan interventions in achieving patient-specific goals.
• Facilitation of benefits preservation through coordination of appropriate level of care and plan compliance.
• Facilitation of recommended treatments with contracted providers to preserve patient benefits and facilitate cost containment objectives.
• Works closely with participant to facilitate understanding of available client benefits and local resources
• Adhere to PruittHealth Premier goals, objectives, standards of performance, and policies and procedures.
• Ensure compliance with quality patient care and regulatory compliance within the company's standards and RN scope of practice.
• Comply with PruittHealth Premier's confidentiality policy, HIPAA requirements and state and federal regulations.
• Supports the highest level of participant-defined quality of life and well-being.
• Responsible for identifying overall quality improvement activities
• Business travel may be required.
• Ability to work in triage and/or disease management role if needed
• Other duties as assigned.

Knowledge, Skills, Abilities:

• Ability to interact with a wide variety of people and handle complex situations simultaneously with customer service focus
• Evidence of creativity, integrity and initiative
• Attention to detail and follow-up.
• Experience with electronic clinical charting/records
• Ability to work independently and be self-motivated in a remote environment
• Manage assigned case load as business needs dictate.
• Excellent time management, flexibility, and efficient organizational skills with ability to work independently and as a team player in both office/remote environment
• Adherence to legal and ethical principles of privacy, confidentiality, safety, advocacy, and accreditation and regulatory standards in all case management activities in both office/remote environment
• Compliance to internal and external goals/metrics established for assigned department
• Position is often required to independently plan and prioritize patient care objectives.
• The ability to analyze and problem-solve

Technical Skills:

• Proficient computer skills in Windows, Care Management Platforms, and general Internet use.
• Ability to chart and follow designated workflow(s) in an electronic environment.
• Proficient in typing

Communication Skills:

• Strong verbal and written communication skills required to meet superior customer service and satisfaction levels.
• Excellent interpersonal skills and ability to function as a member of a multi-disciplinary team.
• Ability to communicate, read, and write fluently in English
• Effective analytical and problem-solving skills

Qualifications:

Minimum Education Required:

• Advanced Nursing Diploma and/or college degree in nursing required.
• Bachelors (or higher) degree preferred.

Minimum Experience Required:

• Minimum two years (full- time equivalent) direct clinical care experience required.
• Minimum three years industry experience in a managed care setting focused on experience in utilization review/case management and at least two years case management, home care or hospice experience strongly preferred.
• Minimum two years experience with long-term care population

Minimum Licensure/Certification Required by Law:

• Licensed Registered Nurse with current, unrestricted license in state of practice (Georgia) required.
• Certified Case Manager preferred Mandatory to apply for CCM certification when eligible.
• Current CPR certification

Additional Qualifications:

• Minimum of Class B driver's license preferred.