Description |
Job Description
Major Duties:
Establishes a collaborative relationship with the client (plan participant), family, physician(s), and other providers to determine medical history and current status to assess the appropriate level of care and options for alternative care. Sets a plan for short term and long term goals, time frames for follow-up, resources available (internal and community), involves all appropriate parties (client, physician, providers, employers, etc), and identifies anticipated case results/outcomes and criteria for case closure. Implements, coordinates, monitors and evaluates the case management plan on an ongoing basis in collaboration with the client and treating providers as appropriate.
Negotiates level of care, intensity and duration with providers(s), as able.
Documents findings in a clear concise manner and continues to evaluate medical necessity of frequency, intensity and length of care with physician(s) and agency/vendor(s) on an ongoing basis.
Acts as liaison between account, client/family, physician(s) and facilities/agencies.
Maintains accurate record (system) of case management interventions
Adheres to quality assurance standards and all case management policy and procedures
Interacts and coordinates referrals to the Medical Directors as necessary. Acts as a preceptor for Case Managers for training and/or performance issue, as able and as assigned. Demonstrates evidence of continuing education, minimally 1 per quarter to maintain clinical expertise.
The Specialty Case Manager interacts with benefit specialist and claims staff for claim payment direction to ensure correct interpretation of transplant contracts and to apply payments accurately
Participates on committees, task forces and other company projects, as assigned. Supports training initiatives or audits of case files, as assigned. Demonstrates sensitivity to culturally diverse situations, clients and customers. Any other assigned tasks as deemed necessary to meet business needs.
Ensures the members privacy, confidentiality, and safety are maintained, adheres to ethical and accreditation standards, serves as a member advocate, and adheres to legal and regulatory standards. Requirements
Qualifications
MUST be bilingual and fluent in both Spanish and English
Active RN license for the state of Florida required
Bachelor Degree in Nursing preferred
CCM certification preferred
Clinical experience in acute or case management within Oncology or Hospice required.
Demonstrated ability as a specialty case manager and ability to assist supervisor with sales/training/account service management. Excellent time management, organizational, research, analytical, negotiation, communication (verbal and written) and interpersonal skills.
Expert knowledge of the insurance industry and claims processing.
Service marketing/account management experience a plus. .
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Requirements |
See job description.
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