Healthcare Manager

Job Reference ID:  12644 Category: Other Duration:  4 Months City, ST:  Orange, California Country:  United States

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Description:
Location: Orange, CA4 MonthsPosition Summary/Mission The nurse consultant utilizes clinical skills in a collaborative
process to assess, plan, implement, coordinate, monitor and evaluate options and
services to facilitate appropriate healthcare outcomes for members. More specifically,
Case Management (CM) is defined as a collaborative process that assesses, plans,
implements coordinates, monitors and evaluates options and services to meet an individual's
health needs through communication and available resources to promote quality, cost-effective
outcomes. The CM process includes: assessing the member's health status and care
coordination needs, inpatient review and discharge planning, developing and implementing
the CM plan, monitoring and evaluating the plan and involving the Medical Director
as indicated and closing the case as appropriate when the member has met discharge
criteria. Fundamental Components and Physical Requirements include but are not limited
to(* denotes essential functions) Identification of Members - Applies data driven
methods of identification of members, following appropriate procedures for identifying,
screening and assessing member needs (*) - Proactive and predictive identification
and appropriate recommendations for referrals to alternative healthcare programs,
e.g. disease management, case management (*) - Conducts comprehensive clinical assessments
of members' care needs and determines approaches to meeting needs either through
Aetna, the member's benefits plan or external programs and services (*) Development
and Implementation of Care Plans - Based on comprehensive assessments, develops
patient case management plans that encompass the physical and psychological needs
of the patient (*) - Evaluates and identifies health care service delivery using
clinical knowledge to sequence services such that the member receives care in the
most appropriate setting at the most appropriate expense (*) - Promotes communication,
both internal and externally to enhance effectiveness of medical management services
(e.g., Physicians, claim administrators, Plan Sponsors, and third party payers as
well as member, family, and health care team members respectively) (*) - Applies
case management concepts to complex issues and problem solving techniques in order
to promote optimum patient outcomes, e.g. evaluates the use of potential alternative
benefits when member's benefit plan does not provide coverage (*) Enhancement of
Medical Appropriateness and Quality of Care - Application and/or interpretation
of appropriate clinical criteria and guidelines, standardized case management plans,
policies, procedures and regulatory standards while assessing Member's needs to
ensure appropriate administration of benefits (*) - Interprets relevant medical
policy/benefits determination to an identified case (*) - Provides the appropriate
level of intervention to facilitate coordination of care (*) - Identifies members
that may benefit from intervention (*) - Advocates for patients to the full extent
of existing health care coverage and programs (*) - Interprets medical policy and
guidelines to make appropriate coverage decisions in unique situations (*) - Identifies
and escalates quality of care issues through established channels (*) Monitoring,
Evaluation and Documentation of Care - Administers the hospital care, case management
and quality management processes in compliance with various laws and regulations,
URAQ and/or NCQA standards, Case Management Society of America (CMSA) standards
where applicable, while adhering to company policy and procedures (*) - Evaluates,
periodically, the member's progress in meeting case management plan goals, and revises
and coordinates plan with attending physician accordingly when appropriate (*) -
Consults with supervisors and/or Medical Directors to overcome barriers to meeting
care plan goals and objectives; presents cases at Medical Director rounds and case
conferences to obtain multidisciplinary review (*) - Ensures accurate and complete
documentation of required information to meet risk management, regulatory, and accreditation
requirements (*) - Protects the confidentiality of member information and adheres
to company policies regarding confidentiality (*) Sedentary work involving significant
periods of sitting, talking, hearing and keying. Work requires visual acuity to
perform close inspection of written and computer generated documents as well as
a PC monitor. Working environment includes typical office conditions Exhibits behaviors
outlined in Case Management Nurse Consultant Competencies Background/Experience
Desired 3-5 years clinical practice experience, preferably in acute care, in a hospital
setting. 2 years managed care case management and/or utilization management experience.
Education and Certification Requirements RN or licensed social worker with active
unrestricted state licensure; Case Management Certification "CCM" preferred, consideration
will be given to allow for obtaining the necessary experience and competencies in
the course of employment. Ideally, a case manager will obtain and maintain CCM within
three years of employment as a case manager. Additional Information (situational
competencies, skills, work location requirements, etc.) Strong customer service
skills to coordinate service delivery including attention to customers, sensitivity
to issues, proactive identification and resolution of issues to promote positive
outcomes for members. Computer literacy in order to navigate through internal/external
computer systems, including Excel and Microsoft Word. Ability to effectively participate
in a multi-disciplinary team including internal and external participants. Initiative,
innovation and creativity. Self directed and motivated to achieve positive outcomes
for members. Excellent/Proven clinical assessment skills with ability to make good
decisions and exercise sound clinical and professional judgment as well as manage
multiple priorities.

Job Created: Wed Nov 04 2009 12:35:02 PM
Last Modified: Mon Nov 09 2009 04:26:36 PM