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Oversees utilization management, care coordination, and discharge planning for patients. Assesses, plans, implements, monitors, and evaluates the services and options available to meet individuals' health needs, using screening criteria, developed critical pathways, and available resources to promote quality cost effective care outcomes. Supports the physician and interdisciplinary team in facilitating patient care in order to enhance the quality of clinical outcomes and patient satisfaction while managing the cost of care and providing timely and accurate information to payers. Identifies areas where performance improvement is needed, such as daily workflow, education, process improvements, and patient satisfaction.: Contributes to profitability and growth through expansion activities in case management (CM) care management. Assists in the development strategy with implementation of strategic, high quality, CM care management customer-specific products. Assists in the development of short- and long-term case management strategies, objectives, and budgets. Serves as resource for other departments in solving problems relating to patients, physicians, providers, payers, vendors, and accounts. Assists in development of and implements departmental and company policies and procedures. Conducts analysis of quality and productivity auditing of staff and departmental workflows. Directly manages licensed staff in CM Department, including interviewing, hiring, and training employees; planning, assigning, and directing work; appraising performance; rewarding and disciplining employees; and addressing complaints and resolving problems. Assists the Director in the development and management of the CM Department budget, including monitoring overtime and associated costs, submitting purchase orders for departmental supplies, recommending additional staff, and assisting with purchases and capital expenditures requiring higher level authorization.

Case Management Supervisor

Supervises the daily operations of the case management function. Communicates with departmental and plan administrative staff to facilitate daily department functions. Assists with the implementation of policies and procedures regarding medical case management. : Facilitates the planning, monitoring, and implementation of care for patients. Coordinates case management activities with medical staff, data informatics, quality and utilization departments, etc. Evaluates patient outcomes and revises treatment plans as needed. Authorizes ancillary services, as needed, after approval by Physician. Ensures that client individual program plans comply and are consistent with client needs, laws, Federal and State regulations, contractual agreements, emergency management policies, and established referral, pre-certification, and authorization policies and procedures. Organizes and supervises liaison activities with community programs. Facilitates ongoing communication between case management staff, utilization management staff, and contracted providers. Acts as medical resource for appeals function. Conducts reviews of cases with doctors, hospitals, and other providers. Identifies trends and assists in financial forecasting. Trains, mentors, supervises, and evaluates case management staff.

Disease Case Manager

Provides intensive, comprehensive case management in a multidisciplinary medical environment, using in-depth clinical knowledge of disease conditions and pharmacological agents, and increases efficient utilization of services for members with a specific diagnosis. Identifies, educates, assists, and manages the health plan patient of various client groups including commercial accounts, Medicare, and Medicaid participants. Develops, implements, and maintains a disease management program for enrollees with a specific diagnosis to include asthma, diabetes, sickle cell, HIV, and high-risk maternity. Typically requires licensure as a Registered Nurse or Registered Respiratory Therapist (depending upon targeted area of assignment) with a minimum of three years of clinical experience working with individuals in ambulatory, acute, or home care settings.: Clinically assesses, identifies, coordinates, educates, and manages members with various disease states while working cooperatively and effectively with the preferred care delivery system to assure high quality, cost effective care for members. Identifies, educates, assists, and manages the health plan patient to promote the best quality of life for the enrollee and control costs associated with healthcare delivery. Develops and implements services that support the disease management program. Performs in-depth screening of enrollees for disease and/or case management eligibility, using predetermined criteria as outlined in the disease case management program. Designs an individual treatment plan in conjunction with Physician for overall care of enrollees. Monitors enrollee's condition on an ongoing basis by means of regular telephone calls and on-site visits. Follows up with inpatients during and after hospitalization. Evaluates enrollee's response to treatment and updates treatment plans as necessary. Maintains ongoing communication with Physician and health plan providers regarding enrollee's condition and response to care.

Inpatient Nurse Case Manager

Coordinates the delivery of healthcare and social services to the inpatient population while balancing individually identified patient and family, medical, and psychosocial needs with cost-effective and available resources. Manages the inpatient hospital stay of a caseload of patients through coordination with physicians, social workers, nursing staff, and other health professionals. Reports to the Nurse Manager of assigned unit.: Performs utilization review and collaborates with the care team to formulate the discharge plan. Implements a plan of care utilizing approved clinical guidelines to transition and provide continuity of care for the patient to an appropriate lower level of care in collaboration with the hospitalist/physician member team, acute or skilled facility staff, ambulatory care team, and the patient and/or patient's representative from admission through discharge. Interfaces with physicians, nursing staff, and other members of the multidisciplinary and medical records coding staff to ensure appropriate reimbursement is received. Determines medical necessity for admission and continued stay according to specific criteria and regulations in accordance with the Utilization Review Plan. Conducts daily/concurrent reviews of charts to rectify any deviation from compliance. Educates staff, physicians, and other members of the multi-disciplinary team on documentation for compliance. Identifies consistent clinical and operational problem areas and facilitates resolutions through participation in the performance improvement process. Acts as liaison for the management and communication of information with the insurance/managed care companies of the assigned patient population.

Case Manager

Coordinates managed care cases of plan members admitted to the provider plan facilities and/or members utilizing services outside the provider plan facilities. Case coordination typically includes prospective and retrospective review that includes, but is not limited to, prior authorization, determining the appropriate level of care and utilization of services, concurrent review, retrospective review, developing discharge plans, and ensuring quality cost effectiveness. Develops a plan of care for patients from admission to discharge. This managed care position is typically filled by a registered nurse with current State license.: Monitors patient progress toward desired outcomes through assessments and evaluations. Develops and administers education and prevention programs. May arrange referrals, consultations, therapeutic services, and confer with other specialists on course of care and treatment.

Medicare Nurse Case Manager

Plans, directs, implements, and evaluates appropriate healthcare services for Medicare patients in conjunction with Physician's treatment plan to ensure that cost effective, quality care is provided. Typically requires licensure as a Registered Nurse with three years of relevant nursing and medical case management experience. Certification as a Case Manager or professional certification in a clinical specialty may also be required.: Coordinates cases that normally include prospective and retrospective review and prior authorization, determining the appropriate level of care and utilization of services, concurrent review, retrospective review, developing discharge plans, and ensuring quality cost effectiveness. Develops a plan of care for Medicare patients from admission to discharge. Monitors patient progress toward desired outcomes through assessments and evaluations. Develops and administers education and prevention programs for Medicare patients. Analyzes referred cases for potential case management interventions. Evaluates the effectiveness of alternate care services and ensures that cost effective, quality care is maintained to meet case management objectives. Determines if proposed medical treatment plans meet contract provisions. May arrange referrals, consultations, therapeutic services, and confer with other specialists on course of care and treatment. May negotiate fees with providers of medical care, agencies, and outside vendors to achieve maximum cost effectiveness.

Associate Case Manager

Plans, directs, implements, and evaluates appropriate healthcare services, under direct supervision, in conjunction with Physician's treatment plan to ensure that cost effective, quality care is provided. Typically requires licensure as a Registered Nurse or LPN with at least two year of relevant nursing experience. : Coordinates cases that normally include prospective and retrospective review and prior authorization, determining the appropriate level of care and utilization of services, concurrent review, retrospective review, developing discharge plans, and ensuring quality cost effectiveness. Develops a plan of care for patients from admission to discharge. Monitors patient progress toward desired outcomes through assessments and evaluations. Analyzes referred cases for potential case management interventions. Evaluates the effectiveness of alternate care services and ensures that cost effective, quality care is maintained to meet case management objectives. Determines if proposed medical treatment plans meet contract provisions. May arrange referrals, consultations, therapeutic services, and confer with other specialist on course of care and treatment.

Nurse Case Manager (Mentor)

Plans, directs, implements and evaluates appropriate healthcare services in conjunction with the physician treatment plan to ensure that cost effective, quality care is provided.: Case coordination normally includes prospective and retrospective review which includes prior authorization, determining the appropriate level of care and utilization of services, concurrent review, retrospective review, developing discharge plans, and ensuring quality cost effectiveness. Develops a plan of care for patients from admission to discharge. Monitors patient progress toward desired outcomes through assessments and evaluations. Develops and administers education and prevention programs. Analyzes referred cases for potential case management interventions. Evaluates the effectiveness of alternate care services and ensures that cost effective, quality care is maintained to meet case management objectives. Determines if proposed medical treatment plans meet contract provisions. Authorizes initiation of medical case management. This position typically requires a licensed Registered Nurse with a minimum of five years of relevant nursing and medical case management experience. Certification as a case manager or professional certification in a clinical specialty may also be required. May arrange referrals, consultations, therapeutic services, and confer with other specialist on course of care and treatment. May negotiate fees with providers of medical care, agencies and outside vendors to achieve maximum cost effectiveness. May provide guidance to less experienced case managers.

Nurse Case Manager

Medical Nurse Case Manager

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