Complex Case Mgr Job
Location: Pikeville, Kentucky
Description: Coventry Health Care is hiring Complex Case Mgr Job right now, this occupation will be designated in Kentucky. More details about this occupation opportunity kindly read the description below. Description:
It?s a great time to put the strength of Coventry Health Care behind your career!Coventry Health Care is a national managed health care company based in Bethesda; Maryland operating health plans; insurance companies; network rental service companies; and worker's compensation service companies. Coventry provides a full range of risk and fee-based managed care products and services; including HMO; PPO; POS; Medicare Advantage; Medicaid; Worker?s Compensation and Network Rental to a broad cross section of employer and government-funded groups; government agencies; and other insurance carriers in all 50 states as well as D.C. and Puerto Rico. Coventry has ?made the list? in three prominent publications: Barron?s 500; Forbes? Platinum 400; and Fortune 500. Coventry is currently seeking a Complex Case Manager to work from home in the Kentucky's Medicaid Region 8 (in or around Pikeville).
GENERAL SUMMARY
The Transitional Care Case Manager will work collaboratively with members of the interdisciplinary team such as the attending physician; specialists and other ancillary providers. Will also work closely with plan pharmacists to determine any medication adherence or reconciliation concerns that could adversely affect the member's recovery from an inpatient admission. The program goals include reduction of readmissions; improved physician follow up and increase in member knowledge of their condition and medications.
- Responsible for the short term management of members identified for the transitional care program by program and condition.
- Responsible for the proactive management of chronically ill members with the objective of improving quality outcomes and decreasing costs.
- Responsible for the early identification and assessment of members for admittance to a short term chronic care management program.
- Applies case management concepts; principles; and strategies in the development of an individualized case plan that addresses the member's broad spectrum of needs. The case planning process includes the following actions: assessment; goal setting; establishing interventions related to goals; monitoring success of the interventions; evaluating the success of the overall case plan; and reporting outcomes.
- Interviews members telephonically; in their home; physician office or in other facilities to provide initial and ongoing case management services.
- Conducts regular discussions and updates with the plan pharmacists and health plan Medical Directors; health services staff. regarding the status of a particular member.
- Serves as the member advocate to ensure they receive all necessary care allowed under their benefit plan. Develops knowledge of community resources and alternate funding arrangements available to the member when services are not available under their benefits program.
- Develops new programs as appropriate to reduce admissions for acute and chronic members and assist with decreasing their lengths of stay.
- Develops relationships with hospital social workers and community resources to assure appropriate management of catastrophic and chronically ill members.
- Develops an understanding of healthcare reimbursement methods that promotes the provision of cost effective healthcare and the preservation of the member benefits.
- Assists in the identification and reporting of potential quality improvement issues. Responsible for assuring these issues are reported to the Quality Improvement Department.
- Collaborate with plan and corporate case managers and social workers as well as plan concurrent review nurses to promptly identify potential cases and refer cases on at the end of the program.
- May serve as liaison and key resource for Appeals Coordinators for cases involving utilization management; case management; and general medical issues.
- May be responsible for handling sensitive appeal cases that involve complex medical issues assuring all regulatory requirements are met. Works closely with senior management and the Legal Department on these cases.
- Maintains confidentiality of member's information in accordance with HIPAA regulations.
- Performs other duties as required.
- MUST be a Registered Nurse with current state license is required
- Previous experience (usually 1+ year) in case management
- Significant experience (usually 3+ years) clinical experience preferably in home care or utilization management.
- Knowledge of community resources is preferred.
- Experience with using computer systems will be part of the clinical activities.
- Excellent communication skills with coaching techniques is required.Coventry Health Care is an Affirmative Action/Equal Opportunity Employer; and we are committed to building a talented and diverse team.
Coventry Health Care is an Affirmative Action/Equal Opportunity Employer, and we are committed to building a talented and diverse team.
Job: Professionals Primary Location: Pikeville, KY, US Organization: CMS - STAR Corporate Schedule: Full-time Job Posting : 2012-07-23 00:00:00.0
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If you were eligible to this occupation, please send us your resume, with salary requirements and a resume to Coventry Health Care.
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This occupation will be opened on: Tue, 24 Jul 2012 16:56:44 GMT
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