Healthcare Consultant III - Care Manager

Key Points of Job

• Must reside in Jefferson County, Kentucky
• This is a Field position that requires regional in-state travel 80-90% of the time
• Minimum of 5 years of experience required

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Position Summary

Intensive Case Manager uses critical thinking and professional judgment to support the case management process and facilitate and maintain improved healthcare outcomes for members by providing advocacy, collaboration, coordination, support, and education through care management tools and resources.

This is a Field position that requires regional in-state travel 80-90% of the time. Qualified candidates must have reliable transportation. Travel to the Louisville office for meetings and training is also anticipated. Travel to members' homes, schools, hospitals, doctors' offices, DCBS offices, etc., is expected for face-to-face membership time. This position is assigned to the Jefferson Region, Jefferson County. Qualified candidates must reside in Jefferson County in the assigned region. Flexibility to work beyond core business hours of Monday-Friday, 8 am-5 pm EST, is required. We serve children and families who may require after-school, after-work, etc., hours.

Evaluation of Members:

• Using care management assessments and information/data review, recommends an approach to resolving care needs, maintaining optimal health and well-being by evaluating the member's benefit plan and available internal and external programs/services.
• Identifies high-risk factors and service needs that may impact member outcomes and implements early and proactive support interventions.
• Coordinates and implements Wellness care plan activities and monitors member care needs.

Enhancement of Medical Appropriateness and Quality of Care:

• Using a holistic approach, consults with case managers, supervisors, Medical Directors, and/or other health programs to overcome barriers to meeting goals and objectives; presents cases at case conferences to obtain multidisciplinary review to achieve optimal outcomes.
• Identifies and escalates quality of care issues through established channels.
• Utilizes negotiation skills to secure appropriate options and services necessary to meet the member's benefits and/or healthcare needs.
• Utilizes influencing/ motivational interviewing skills to ensure maximum member engagement and promote lifestyle/behavior changes to achieve optimum level of health.
• Provides coaching, information, and support to empower the member to make ongoing independent medical and/or healthy lifestyle choices.
• Helps members actively and knowledgeably participate with their provider in healthcare decision-making.

Monitoring, Evaluation and Documentation of Care:

• Utilizes case management and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures.

Required Qualifications & Skills

• Minimum 6 months' experience in Foster Care and juvenile justice systems, Adoption Assistance, the delivery of Behavioral Health Services, Trauma-informed Care, ACEs, Crisis Intervention services, or evidence-based practices applicable to the Kentucky SKY populations is required.
• Minimum 2 years of experience required in behavioral health, social services, social work, psychology, sociology, marriage and family therapy, or counseling.
• Minimum 1 year of experience in MS Office Suite applications, including Word and Excel.
• Willing and able to travel 80-90% of their time to meet members face-to-face in their assigned region.
• Candidate must reside in Jefferson County

Preferred Qualifications

• 3+ years' experience required in behavioral health, social services, social work, psychology, sociology, marriage and family therapy, or counseling.
• 1+ MCO experience

Duties

• Determines medical necessity/ appropriateness
• Facilitates optimal outcomes
• Identifies and follows through with continuous quality/ compliance opportunities. xhyhwjd May also include identification of aberrations and initiation of corrective action
• Educates/ empowers customers to ensure compliance, satisfaction, and promote patient advocacy
• Optimize total costs; implementation and evaluation of policy based on usage and program directives
• Educate/empower colleagues at all levels to enable decision-making at the most appropriate level

Education

• Bachelor's degree in a relevant subject

Schedule

• M-F 8 am-5 pm, with the flexibility to work until 7 PM in the EST time zone.