Description:
BASIC FUNCTION:
This position is responsible to provide care coordination to members via telephonic and/or field based care management to inform and educate them on health care programs to address their personal health needs, engage the member in adherence to personal health goals, respond to inquiries from members, and support the clinical operations department with their provider and member activities. This position will be required to complete member telephone and/or field based health screenings, comprehensive health assessments and care planning duties which may require visits to members’ home and/or facilities to support complex and specialty populations.
ESSENTIAL FUNCTIONS:
Serve as the primary point of contact for members and perform ongoing functions to support the Clinical Operations Department, including one or more of the following:
1. Perform long-term or short-term care coordination support through member outreach, follow up, assistance with transitions of care, and resource referrals. Through the use of health screenings and/or comprehensive assessment tools, evaluate members needs initially, annually and upon condition changes to obtain history relevant to medical and non-medical conditions and work with members to create and/or update their care plan, as needed.
2. Coordinates healthcare and service needs, monitors, and assesses progress of case management plan for complex cases and specialty teams, as required by state and federal regulators, through regular member telephonic or face-to-face(home or facility visit) contact.
3. Inform and educate members on the Care Management Programs, disease management, benefits and community resources to support access to services or health related social needs.
4. Promote member engagement through building relationships to foster the development, implementation, and adherence to person-centered care plans that address individual healthcare needs and goals of members, their benefit plan, long-term services and supports, and community resources, as applicable.
5. Generate appropriate correspondence and send to member manually, electronically, or telephonically.
6. Maintain production and documentation requirements based on established department business needs and work assignments.
7. Receive, analyze, research and respond to telephone and/or written inquiries by processing information from member or provider to determine needs/wants and ensure member/provider questions have been addressed or routed to the appropriate internal party for resolution.
8. Support and maintain communications with various entities to facilitate and coordinate interdisciplinary team meetings and collaboration for member care.
9. Communicate and interact effectively and professionally with co-workers, management, customers, etc.
10. Assist to identify complex member issues and engage leadership for guidance as needed.
11. Provide audit readiness support and navigation.
12. Support business and program initiatives.
13. Practice within the scope of licensure within the state regulations and with the URAC/NCQA accreditation standards.
14. Attend monthly/quarterly meetings as requested.
15. Support & promote health initiatives and be knowledgeable of applicable benefit programs
16. Participate/facilitate in various classes/meetings designed for the members.
17. May handle or assist in training other staff.
18. Any additional special projects, initiatives or meetings as requested.
19. Communicate and interact effectively and professionally with co-workers, management, customers, etc.
20. Comply with HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies and other applicable corporate and departmental policies.
21. Maintain complete confidentiality of company business.
22. Maintain communication with management regarding development within areas of assigned responsibilities and perform special projects as required or requested.
JOB REQUIREMENTS:
Registered Nurse (RN) with 2 years direct clinical care to the consumer in a clinical setting or , unrestricted Licensed Professional Counselor (LPC, TX), or Licensed Master Social Worker (LMSW, TX, NM), Licensed Clinical Professional Counselor (LCPC, IL) or Licensed Clinical Social Worker (LCSW, IL & NM) Licensed Marriage and Family Therapist (LMFT, IL & NM), Licensed Professional Clinical Counselor (LPCC, NM), Licensed Independent Social Worker (LISW, NM), or Licensed Mental Health Counselor (LMHC, NM) with 2 years of clinical practice experience. Current, valid, unrestricted license in the state of operations (or reciprocity). For compact licensee changing permanent residence to state of operations, you must obtain active, unrestricted RN licensure in the state of operations within 90 days of hire.
Plus 3years wellness or managed care experience presenting clinical issues with members/physicians.
Experience handling medical management programs and health educations programs in an independent manner.
Knowledge of the health and wellness marketplace and employer trends.
Verbal and written communication skills including discussing medical needs with members and interfacing with internal staff/management and external vendors and community resources.
Analytical experience including medical data analysis.
PC proficiency to include Word, Excel, and PowerPoint, database experience and Web based applications.
Ability and willingness to travel within assigned territory.
PREFERRED JOB REQUIREMENTS:
3 years clinical experience.
Patient education experience.
Condition Management experience.
Bilingual in English and Spanish.
Experience in managing complex or catastrophic cases.
Certification in Case Management, Training, Project Management or nationally recognized health care certification.
Government Programs experience
Population Management
Required Qualification(s)
Clinical license
Notes:
Contract to Hire
VIVA is an equal opportunity employer. All qualified applicants have an equal opportunity for placement, and all employees have an equal opportunity to develop on the job. This means that VIVA will not discriminate against any employee or qualified applicant on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status