QualChoice of Arkansas
 
Position Title

Care Manager

Job Title

Care Manager

Job Description

POSITION SUMMARY

The Care Manager works with clients, families, physicians, and other health care providers to facilitate, educate and coordinate the provision of health care services for clients. The Care Manager identifies clients who would benefit from care management services, assesses client needs, identifies treatment alternatives, develops individualized care plans, facilitates communication among providers and clients/families, and implements and monitors care plans to promote positive, high quality outcomes.
Outcomes are expected to impact the following areas:

1. Improve Health Outcomes
2. Activities to Prevent Hospital Readmission
3. Improve Patient Safety and Reduce Medical Errors
4. Wellness & Health Promotion Activities


PRIMARY DUTIES AND RESPONSIBILITIES

The Care Manager is responsible for the following:

Assesses referred cases or other available data to identify clients who would benefit from care management services. Assess participant needs and theory of change utilizing a holistic point of view.

Provides utilization review, preauthorization, case management, disease management and medical claims review as indicated.

Preauthorizes services according to established criteria.

Assesses the needs of the client and family and identifies treatment alternatives that promote quality, cost-effective outcomes.

Reviews pertinent medical history, current diagnosis, and pharmaceutical data via information database system.

Communicates with practitioners, providers, clients, family members, Medical Directors, and appropriate QualChoice personnel regarding client needs and treatment alternatives.

Coordinates development, approval, and implementation of care plans.

Utilizes readiness for change, locus of control assessments and productivity measures to guide care.

Assists clients in forming solutions for presenting problem and co-defines and determines realistic goals with participant.

Determines and provides relevant community and/or healthcare resources that help support participants theory of change and effective and efficient medical utilization.

Educates members and coaches to a healthy lifestyle according to established criteria.
POSITION DESCRIPTION POSITION: Care Manager 02/21/13
DEPARTMENT: Quality and Care Management REPORTING TO: Quality and Care Management Supervisor POS#

Establishes and maintains good working relationships with physicians, hospital staff, allied provider contacts, clients and families.

Directs member to network providers, community resources, online resources and employer sponsored services according to the needs of the client.

Coaches the client utilizing motivational interviewing techniques.

Monitors the effectiveness of care management plans in achieving quality, cost-effective outcomes, through ongoing communication with clients, families, physicians, and other providers, as well as medical record review and/or onsite client evaluation. Facilitates changes in care plans as indicated.

Assures that Medical Director and departmental management are informed of care status according to established procedures. Seeks direction on medical or administrative issues as needed. Documents according to accepted medical record standards consistently and thoroughly.

Provides documentation as needed to ensure proper claims payment.

Effectively assesses, coaches and graduates clients from care, resulting in appropriately managed caseloads.

Maintains open lines of communication within the organization.

Is familiar with and functions within national Health coaching and Care Management standards.

Manages care in a compassionate, quality, cost effective manner.

Fosters a team relationship with other department staff.

Other duties as assigned.


RELATED SKILLS

Excellent written and verbal communication skills.
Exceptional organizational skills.
Ability to work independently, communicate effectively and collaborate with other healthcare professionals, clients and families.
Strong negotiation and problem-solving skills.
Ability to handle conflict and to exercise sound judgment.
Basic typing and computer skills.
Familiarity with HCPCS, CPT-4 and ICD-9 coding helpful.
Understanding of adult learning principles.
Familiar with Prochaska Change theory and ability to utilize during assessment.

Basic Qualifications

EDUCATION AND EXPERIENCE

Registered Nurse with an active Arkansas license.
Minimum of five years of broad-based nursing experience.
Prefer experience in utilization review, care management, discharge planning, home health, and/or managed care.

Ability to perform the following with or without reasonable accommodations:
Provide telephonic and web-based coaching services using PC and
multi-line telephonic technology
Read, write and speak, with or without reasonable accommodations, and communicate effectively via these mediums.
See a computer screen and read small type
Understand verbal commands and information transmitted via the
telephone, in person or through written language
Sit, stand, bend and lift up to 40 pounds
Type using standard keyboard

Physical Demands:
Ability to meet with associates in their cubicles and/or meeting rooms.
Ability to sit for periods of up to 3 hours without a break.
Ability to lift 10 to 20 pounds and over 20 pounds with assistance.
Ability to communicate over telephone.

Other Duties

PRIMARY DUTIES AND RESPONSIBILITIES

The Care Manager working in disease management and health coaching is responsible for the following:

Assesses referred cases or other available data to identify clients who would benefit from care management services. Assess participant needs and theory of change utilizing a holistic point of view.

Utilize readiness for change, locus of control assessments and productivity measures to guide care.

Assesses the needs of the client and family and identifies treatment alternatives that promote quality, cost-effective outcomes.

Review pertinent medical history, current diagnosis, and pharmaceutical data via information database system.

Communicates with practitioners, providers, clients, family members, Medical Directors, and appropriate QualChoice personnel regarding client needs and treatment alternatives.

Coordinates development, approval, and implementation of care plans.

Assists clients in forming solutions for presenting problem and co define and determine realistic goals with participant.

Determine and provide relevant community and/or healthcare resources that help support participants theory of change and effective and efficient medical utilization.

Educates members and coaches to a healthy lifestyle according to established criteria.

Establishes and maintains good working relationships with physicians, hospital staff, allied provider contacts, clients and families.

Directs member to network providers, community resources, online resources and employer sponsored services according to the needs of the client.

Coordinates and facilitates for acute medical and resource needs.

Coaches the client utilizing motivational interviewing techniques.

Monitors the effectiveness of care management plans in achieving quality, cost-effective outcomes, through ongoing communication with clients, families, physicians, and other providers, as well as medical record review and/or onsite client evaluation. Facilitates changes in care plans as indicated.

Assures that Medical Director and departmental management are informed of care status according to established procedures. Seeks direction on medical or administrative issues as needed. Documents according to accepted medical record standards consistently and thoroughly.

Provides documentation as needed to ensure proper claims payment.

Effectively assess, coach and graduate clients from care, resulting in appropriately managed caseloads.

Maintains open lines of communication within the organization.

Is familiar with and functions within national Health coaching and Care Management standards.

Manages care in a compassionate, quality, cost effective manner.

Fosters a team relationship with other department staff.

Other duties as assigned.

RELATED SKILLS

Excellent written and verbal communication skills.
Exceptional organizational skills.
Ability to work independently, communicate effectively and collaborate with other healthcare professionals, clients and families.
Strong negotiation and problem-solving skills.
Ability to handle conflict and to exercise sound judgment.
Basic typing and computer skills.
Familiarity with HCPCS, CPT-4 and ICD-9 coding helpful.
Understanding of adult learning principles.
Familiar with Prochaska Change theory and ability to utilize during assessment.

 
 
   
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