Case Manager Catastrophic-rn/lcsw
TriWest Healthcare Alliance (San Diego, California)

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COMPANY OVERVIEW TriWest Healthcare Alliance, headquartered in Phoenix, Arizona, manages and administers quality healthcare services for our nation's active and retired uniformed military service members and their families, through a contract with the Department of Defense. These individuals are eligible for the DoD's regionally managed health care program for the military, called TRICARE. TriWest manages and administers TRICARE throughout the 21-state TRICARE West Region. In addition to supporting military families through the TRICARE program, TriWest has developed relationships with organizations such as the USO, Fisher House, the Women in Military Service for America Memorial Foundation and other military relief and support associations to strengthen America's military community locally and nationally. TriWest provides state-of-the-art facilities, a smoke/tobacco-free, drug-free, business casual working environment, and offers a competitive compensation package including excellent benefits. For more information about TriWest, please explore our website at www.triwest.com. DOD STATEMENT 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. JOB SUMMARY/DESCRIPTION Job Summary: Provides case management services for TriWest beneficiaries. Identifies beneficiaries appropriate for case management and completes a comprehensive assessment. Develops an individualized case management plan of care along the health care continuum in a cost effective manner. Implements the care plan and continuously reassesses needs, plan effectiveness and outcomes of care. Reviews and processes authorization and referral requests according to policy. Key Responsibility Areas: 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. Documents the process by mailing the case management enrollment information and acceptance letter to the beneficiary. Provides timely decision of acceptance into the Case Management Program and completes appropriate notification. 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 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. o Evaluates case management outcomes, assessing the individual beneficiarys 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, ensuring the welfare and safety of the beneficiary. o Supports beneficiaries with finding specialized services outside the network by identifying providers, exploring nature of services offered, and facilitating process. o Supports beneficiaries outside of the case management program by providing TRICARE and community resource information and internal care referrals. o 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 For cases with issues beyond the scope of Social Work practice, the Case Manager with Social Work license refers cases for assessment and consultation to a Case Manager with Medical / Surgical background. Conversely, the Case Manager without Behavioral Health background refers mental health aspects to a Social Worker or Registered Nurse with Behavioral Health background for assessment and consultation. o Provides direction to non-clinical staff on clinical and coding questions. o Assists in orienting and coaching new employees in the Case Management Program as necessary, including TRICARE and TriWest policies and procedures, and medical management system. Working Conditions: o Availability to cover any day shift o Works within a standard office environment , with minimal travel required o Extensive computer work with long periods of sitting o Department of Defense security clearance required QUALIFICATIONS Education & Experience: Required: o Licensed Clinical Social Worker with a Masters Degree, with current unrestricted state license or RN with current unrestricted state license For RN candidates, one of the following required: o Bachelors degree in a health-related field and 3 years Medical Surgical clinical experience or o 5 years of Medical-Surgical clinical experience Preferred: o 2+ years of Case Management experience or equivalent o Case Manager Certification (URAC-recognized) o Experience with case management strategies, including clinical protocols, best practices, new treatments, new technologies, developmental stages, and beneficiary education Knowledge & Skills: Technical Knowledge: Case Management, Utilization Management, 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 Communication / People Skills: Ability to influence or persuade others under positive or negative circumstances; Adapt to different styles; Listen critically; Collaborate and negotiate Team-Building / Team Player: Influence the actions and opinions of others in a positive direction and build group commitment Coping / Flexibility: Resiliency in adapting to a variety of situations and individuals while maintaining a sense of purpose and mature problem-solving approach, crisis intervention and conflict-resolution 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 Computer Literacy: Ability to function in a multi-system Microsoft environment using Word, Outlook, PowerPoint, company Intranet, the Internet, and department software applications 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 Multi-Tasking / Time Management: Prioritize and manage actions to meet changing deadlines and requirements within a high volume, high stress environment BENEFITS TriWest offers a comprehensive and progressive benefits package that includes: o Medical, dental and vision coverage o Generous paid time off o 401(k) Retirement Savings Plan (with matching) o Short-term and long-term disability, basic life, and accidental death and dismemberment insurance o Voluntary plans such as pet insurance, long-term care and 529 College Savings Plans o Reimbursement for various wellness initiatives o Tuition reimbursement 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.