Job: Case Manager-Med/Surg
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Provides Case Management services for TriWest beneficiaries. Screen referrals for Case Management and completes a comprehensive assessment. Develops an individualized case management plan of care, implements the care plan and continuously reassesses needs, plan effectiveness and outcomes. Reviews and processes authorization and referral requests according to policy. Case Managers are responsible for reviewing and understanding the scope of practice of their state of licensure.
o Applies knowledge of HIPAA privacy and security regulations as well as URAC accreditation standards to ensure compliance in daily practice.
o Screens beneficiary needs and circumstances with predetermined program criteria to determine appropriateness for case management. Identifies beneficiaries at high-risk for significant adverse health outcomes and with high-cost, clinical and psychological factors impacting care.
o Documents the process by providing the case management enrollment information and acceptance letter to the beneficiary. Provides timely decision of acceptance into the case management program and completes appropriate notifications.
o Completes comprehensive case management assessments. Develops individualized case management care plans to assist beneficiaries with obtaining access to quality care in a cost-effective manner. Obtains necessary agreements for obtaining protected health information as needed. Mails or faxes the care plan to the Primary Care Manager or Behavioral Health provider for information and input.
o Reassesses and monitors care plans for adjustments on a monthly basis to address newly-identified needs, services, treatment, and funding options (every other month for maintenance program). Documents changes in the care plan maintained in the medical management system.
o Evaluates case management outcomes, assessing the individual beneficiary's satisfaction and compliance with the care plan.
o Prepares and presents cases involving high-profile or sensitive issues to the Medical Director for review.
o Functions as an advocate for the beneficiary by ensuring access to necessary care and maintaining beneficiary's safety, locating specialized services outside the network by identifying providers, exploring nature of services offered, and facilitating process.
o Supports beneficiaries by providing TRICARE and community resource information and internal care referrals as needed to meet care plan goals.
o Understands Administers the TRICARE Specialty Program benefits, including program registration, enrollment, authorizations, and screening for high risk factors indicating appropriateness for catastrophic case management services.
o Monitors and provides direction to non-clinical staff.
o Regular and reliable attendance is required.
Skills / Requirements
Education & Experience
o Current unrestricted state license as Licensed Clinical Social Worker, Registered Nurse, or Clinical Psychologist.
o Two years full-time equivalent of direct clinical care to the consumer
o Ability to obtain a URAC-recognized certification in case management within four (4) years of hire*
* For case managers hired before January 1, 2010, certification described above must be obtained within four (4) years of January 1, 2010.
o 2 years case management experience
o URAC-recognized case manager certification upon hire
Communication / People Skills: Ability to influence or persuade others under positive or negative circumstances; Adapt to different styles; Listen critically; Collaborate.
Computer Literacy: Ability to function in a multi-system Microsoft environment using Word, Outlook, TriWest Intranet, the Internet, and department software applications.
Coping / Flexibility: Resiliency in adapting to a variety of situations and individuals while maintaining a sense of purpose and mature problem-solving approach is required.
Empathy / Customer Service: Customer-focused behavior; Helping approach, including listening skills, patience, respect, and empathy for another's position.
Independent Thinking / Self-Initiative: Critical thinkers with ability to focus on things which matter most to achieving outcomes; Commitment to task to produce outcomes without direction and to find necessary resources.
Multi-Tasking / Time Management: Prioritize and manage actions to meet changing deadlines and requirements within a high volume, high stress environment.
Organizational Skills: Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; Detail-oriented.
Problem Solving / Analysis: Ability to solve problems through systematic analysis of processes with sound judgment; Has a realistic understanding of relevant issues.
Team-Building / Team Player: Influence the actions and opinions of others in a positive direction and build group commitment.
Technical Skills: Thorough knowledge of TRICARE policies and procedures, Case Management, Utilization Management, HIPAA Privacy and Security regulations, URAC accreditation standards, Managed Care concepts, Behavioral Health practices and principles, Medicaid and Medicare eligibility requirements and benefits, community resources, alternative funding programs, medical management system, and protected health information; Proficiency with InterQual ISD? criteria (Intensity of Service/Severity of Illness/Discharge Screens); working knowledge of medical coding
You are applying for a position that involves working on electronic systems that have access to Department of Defense ('DoD') systems. Therefore, you must undergo a DoD background investigation. This requires you to submit an application describing the previous 7 years of your life and to provide proof of U.S. citizenship in the form of a certified birth certificate, certificate of naturalization, current passport, form FS-240 or form DS-1350. This process takes several months to complete. During this time, the DoD will grant interim access to U.S. citizens allowing them to work for TriWest until their background investigation is completed. However, the DoD will not authorize interim access for non-U.S. citizens. If you are unable to obtain interim access or pass the background investigation, you are not qualified for this position and TriWest will withdraw any offer of employment or terminate your employment immediately.
Equal Employment Opportunity
TriWest Healthcare Alliance is an equal employment opportunity employer. Applicants are considered for positions without discrimination on the basis of race, color, religion, sex, national origin, age, disability or any other consideration made unlawful by applicable federal, state, or local laws.