Our Healthcare Insurance client is seeking a Case Manager to join their team for a contract role!
Our client has over 5,000 employees and is the number 1 health insurer in the state of North Carolina, serving more than 3.89 million customers. Health care is changing, and our client is leading the way by providing innovative solutions that simplify the health care system, improve efficiency and outcomes, and help rein in costs. Our client is a not-for-profit with headquarters in Durham, NC.
Position: Case Manager
Term: 6 + Months
Location: ** While the position is Remote, work from home, you must reside in North Carolina or one of the following states: Alabama, Arizona, Arkansas, Colorado, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Michigan, Mississippi, Missouri, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, and Wyoming
- RN Licensure required
- Must have NC Licensure or Compact Licensure
- Must be well versed with navigating and toggle computer systems working with multiple screens, must have proficient computer skills, excellent typing skills, must have proficient computer skills with understanding and performance basic knowledges. Must have working knowledge of operating computer systems.
- Must be hard wired to computer, cannot use Wi-Fi. Phone calls conducted through Genesys which requires hardwired capability.
- Secure internet connection and to be hardwired so that systems can function efficiently in order to complete job duties. Wired broadband services with a consistent, minimum internet speed of 768K upload and 6Mb download. Internet Connection through Modem using Ethernet Cable (No WiFi or Hotspot)
The Case Manager coordinates the care and services of selected member populations across the continuum of care, promotes effective utilization and monitoring of health care resources, and assumes a collaborative role with all members of the healthcare team to achieve optimal clinical and resource outcomes.
- Serve as a team member on a multidisciplinary team that monitors utilization patterns; identifies and facilitates appropriate health care service delivery for selected members, providers, procedures, and/or diagnoses; and improves the quality and cost efficiency of care and service.
- Application of knowledge and clinical skills will vary across the Health Care division, dependent on focus areas identified by the business area supported.
- Outreach to members identified as high risk, high cost, or high utilization cases.
- Encourage pro-active intervention to limit expense and encourage positive outcomes.
- Perform a comprehensive assessment of the members health status, educational, and level of support needs.
- Develop a member-centric care plan which includes a self-management plan tailored to members needs, and identification of barriers to meeting goals or plan of care.
- Utilize community resources and funding sources in the development of the plan of care.
- Perform ongoing monitoring and management of member including: scheduled follow-up with member, discussion of plan with member, appropriate services/education to address needs, appropriate referrals with supporting documentation, assessment of progress towards goals, modification of plan/goals as needed, with contact frequency appropriate to member acuity.
- Evaluate and facilitate care provided to members through the continuum of care (physician office, hospital, rehabilitation unit, skilled nursing facility, home care).
- Review alternative treatment plans for case management candidates and assess available benefits and the need for benefits exception or flex benefit options, where eligible.
- May evaluate medical necessity and appropriateness of services as defined by department.
- Document all aspects of the plan from the initial assessment, development of the plan, implementation, monitoring, and evaluating outcome.
- Complete all correspondence related to case management, including all calls and faxes with phone and fax numbers noted. Obtain consents as indicated.
**Manage member when already home, follow patient from hospital to home care.
Work within Que System,
1. Que 1: H2H- Hospital to Home, work with member who were inpatient and released to go home who may be high risk for readmission, 10-25 calls per team in que shared by team.
2. Que 2: Complex Care Mgmt.: Any member/patient with diagnosis or disorder that requires further handling, general information.
3. Que 3: Condition Care: Focus on certain diagnosis, ex: respiratory illness, high risk, cardiovascular care diabetes, Identify differences.
****To be eligible to contract at this client you must be able to pass a drug test and criminal background check.