Case Manager Rn - 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 with a focus on cases located within or transitioning to 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. Provides guidance and training to LPN Service Coordinators.

 

Essential Functions:

Conducts face-to-face Health and Functional Assessments (HFA) for all members on an annual or more frequent basis (as applicable). Conducts a functional level of care assessment using DHS Form 1147 on an annual basis (if appropriate skill set) and sends to the Hawaii Department of Human Services (DHS) or its designee. 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.  Provides counseling on options regarding institutional placement and HCBS alternatives.  Assists members in transitioning to and from nursing facilities/residential facilities.  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)

Licensure in the state of Hawaii for a licensed nurse (RN) Minimum of 1 year of relevant healthcare (preferably in long-term care) experience. 3 -5 years desired. Experience working with Geriatrics preferred Experience working as a Case Manager Experience in working with special populations, such as HIV/AIDS, developmental disabilities, medically fragile children, persons with neurotrauma, and younger adults with physical disabilities Certified Case Manager (CCM) preferred 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