Case Manager Lpn - Oahu - Pr
WellCare (Hawaii, Hawaii)

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Job Summary:

Coordinates, monitors and ensures that appropriate and timely primary, acute and long-term care services are provided to members across the continuum of care excluding within nursing facilities. Assists with coordinating services with federal and state programs, and other community services to the member. Promotes effective healthcare utilization, monitors health care resources and assumes a leadership role within the Interdisciplinary Care Team (ICT) to achieve optimal clinical and resource outcomes. Works with the Manager of Service Coordination to assess, plan, implement, coordinate, monitor, and evaluate services and outcomes to maximize the health of the Member. Receives and reviews authorizations for services from providers and members via phone, fax or written request. Assists RN level Service Coordinators with aspects of their case load and administrative duties when needed.

Essential Functions:

•Conducts face-to-face Health and Functional Assessments (HFA) for all members on an annual or more frequent basis (as applicable).
•Develops a Care Plan for each member, in conjunction with the PCP and member, based upon the outcomes of the HFA.
•Coordinates a team of decision makers including the PCP, other providers as appropriate, the member, and others as determined by the member including family members, caregivers, and significant others to become part of a member’s Interdisciplinary Care Team (ICT).
•Coordinates services with other providers such as Medicare, DOH Programs, Medicare Advantage Plans, specialty providers, Zero-to-Three, HealthStart, mental health, and Developmentally Disabled/Mentally Retarded (DD/MR) providers at DOH.
•Maintains HIPAA standards and confidentiality of protected health information; and reports critical incidents and information regarding quality of care issues.
•Utilizes compiled data received from member encounters to assure that the services being provided meet the member’s needs.
•Facilitates member and provider authorization and access to services.
•Seeks to resolve any concerns about care delivery or providers.
•Monitoring of the member self-direction delivery process
•Monitors progress with Early and Periodic Screening, Diagnosis and Treatment (EPSDT) requirements.
•Refers members who with suspected severe emotional, behavioral and/or mental illness for evaluation;
•Manages a caseload that does not exceed 1880 hours annually, based on case intensity and acuity.
•Acts as liaison and member advocate between the member/family, physician and facilities/agencies.
•Maintains accurate records of service coordination activities in the system using clinical guidelines.
•Ensures compliance with all state and federal regulations and guidelines.
•Perform other duties as assigned.

 

Knowledge, Skills, Abilities Required:

 

•Assists in evaluating process improvements.
•Works independently, handles multiple assignments and prioritizes workload.
•Seeks help in managing workload, when appropriate.
•Demonstrates teamwork and negotiation skills.
•Communicates effectively in person and by phone, travels to member’s location of residence and uses a laptop computer to complete the HFA, initial care plan and documentation.

Education/Experience: (include any licenses or certifications required)

High School diploma or GED equivalent Minimum of 1 year of long-term care or other relevant health care experience. 2-4 years desired. Licensed Practical Nurse (LPN) in the State of Hawaii Managed care experience preferred

 

Communication and Numeric Skills:

Advanced ability to communicate on any level required to meet the demands of the position Ability to create, review and interpret treatment plans Bi-lingual in English and any of the following languages preferred: Ilocano, Tagalog, Mandarin Chinese, or Korean a plus

 

Computer Skills:

Knowledge of Micro Soft Office including Excel, Word and Outlook Knowledge data entry, documentation and report generation in any clinical system a plus