What are the responsibilities and job description for the Full Time Case Manager position at ProviDRs Care?
Position Overview:
The Case Manager RN will play a critical role in providing personalized care coordination and management services to members of a Third-Party Administrator (TPA) health insurance plan. This individual will work directly with patients, providers, and healthcare teams to ensure members receive appropriate, cost-effective care while navigating the complexities of the healthcare system. The case manager will focus on improving health outcomes, managing chronic conditions, and reducing healthcare costs through efficient and compassionate case management.
Key Responsibilities:
- Care Coordination:
- Collaborate with healthcare providers, patients, and their families to develop and implement comprehensive care plans.
- Facilitate communication between healthcare teams to ensure continuity of care and coordination of services.
- Coordinate referrals, hospital discharge planning, and follow-up care for members.
- Member Support:
- Act as the primary point of contact for members, addressing their healthcare needs, answering questions, and providing guidance on health plan benefits.
- Assist members in navigating the healthcare system, including scheduling appointments, and arranging transportation.
- Educate members on their conditions, treatment plans, and wellness strategies to promote self-management and prevent hospital readmissions.
- Quality Review:
- Identify high-risk members and proactively intervene with targeted case management strategies.
- Monitor patient outcomes, track progress, and adjust care plans as necessary.
- Documentation and Compliance:
- Maintain accurate, timely, and comprehensive case notes, adhering to company policies and regulatory standards.
- Ensure all case management activities are compliant with federal and state regulations, accreditation standards, and health plan requirements.
- Participate in regular audits, reviews, and updates of case management procedures to maintain quality assurance.
- Collaboration with TPA Team:
- Work closely with other departments within the TPA (e.g., Claims, Provider Relations, Account Managers) to ensure seamless support for members.
- Contribute to case management reporting, performance metrics, and process improvement initiatives.
Required Qualifications:
- Education:
- Must hold an active Registered Nurse (RN) license in the state of Kansas. The RN license must be in good standing, with no disciplinary actions or restrictions
- Experience:
- Minimum of 1 year of experience in case management, care coordination, or a related role within the healthcare or health insurance industry preferred.
- Experience working with TPA companies, health plans, or managed care organizations preferred.
- Skills:
- Strong knowledge of healthcare systems, medical terminology, chronic diseases and conditions, and treatment protocols.
- Familiarity with medical treatments, medications, and care pathways to ensure appropriate interventions are planned.
- Strong understanding of common conditions like diabetes, heart disease, COPD, and mental health disorders to guide care plans.
- Understanding the various levels of care (acute, post-acute, outpatient, home care, etc.) and how to transition patients between them.
- Knowledge of different healthcare providers and specialists (e.g., primary care, hospitals, rehabilitation centers) and how to collaborate with them.
- Strong knowledge of how to develop and implement personalized care plans based on patient needs, goals, and preferences.
- Proficient in Microsoft Office Suite (Word, Excel, Outlook) and use of computer software programs for data entry.
- Basic knowledge of data collection and data analysis.
- Excellent interpersonal, organizational, and time management skills.
- Ability to work independently and manage a caseload effectively in a part-time capacity.
Key Competencies:
- Patient Advocacy: Ability to advocate for the patient’s needs and ensure they receive high-quality, appropriate care.
- HIPAA: Knowledge of privacy regulations to protect patient confidentiality and appropriately share health information.
- Utilization Management: Familiarity with criteria for approving treatments and services (e.g., pre-authorizations, medical necessity) and ensuring cost-effective care.
- Billing and Coding: Basic knowledge of healthcare billing codes (CPT, ICD-10, HCPCS) to assist with claims and ensure appropriate billing.
- Patient Consent: Understanding of the legal requirements for obtaining patient consent, especially for case management and coordination services.
- Mental Health: Understanding of mental health issues, including depression, anxiety, and substance abuse, and how they affect physical health and care coordination.
- Cultural Competence: Knowledge of how cultural, religious, and social factors influence patient care and the ability to provide culturally sensitive support.
- Problem-Solving: Ability to assess complex situations, identify potential barriers, and implement practical solutions.
- Assessment and Evaluation: Proficiency in assessing patient needs, setting goals, and evaluating progress over time.
- Risk Management: Identifying risks to patient well-being (e.g., hospital readmissions, medication non-compliance) and developing strategies to mitigate them.
- Documentation: Clear and accurate documentation of patient interactions, care plans, and services provided, ensuring compliance with regulatory and payer requirements.
- Social Services: Knowledge of community services like housing assistance, food programs, transportation services, and financial support to help address social determinants of health.
- Communication: Strong written and verbal communication skills.
- Teamwork: Collaborative mindset, working effectively with other team members across departments to achieve member outcomes.
Schedule:
- 40 hours per week, Monday through Friday, 8 a.m. - 5 p.m.
- No on-call, no weekends, no holidays
Compensation:
- Competitive hourly rate based on experience.
- Benefits may include paid time off and participation in 401k plan after 1 year of employment. Full-time benefits take effect 30 days after employment begins.
Job Type: Full-time
Pay: From $31.00 per hour
Expected hours: 40 per week
Benefits:
- 401(k)
- Dental insurance
- Flexible spending account
- Health insurance
- Health savings account
- Paid time off
- Retirement plan
- Vision insurance
Schedule:
- Day shift
- Monday to Friday
Application Question(s):
- How many years of experience do you have working with electronic medical records?
Experience:
- Microsoft Excel: 1 year (Required)
- Microsoft Outlook: 1 year (Required)
- Microsoft Word: 1 year (Required)
- Care Coordination: 1 year (Required)
Work Location: In person
Salary : $31