Job Description

Job Description

Job Description

Summary:

This is a full-time telework role in Kansas, requiring 50-75% travel for face-to-face visits in the assigned area once COVID restrictions are lifted. The schedule is Monday-Friday, standard business hours.

Develop, implement, support, and promote Health Services strategies, tactics, policies, and programs that drive the delivery of quality healthcare to establish a competitive business advantage for the Client. Health Services strategies, policies, and programs are comprised of utilization management, quality management, network management, and clinical coverage and policies. Utilize critical thinking and judgment to collaborate and inform the case management process, in order to facilitate appropriate healthcare outcomes for members by providing care coordination, support, and education through the use of care management tools and resources.

• Evaluation of Members:
• Conduct comprehensive evaluation of referred member's needs/eligibility using care management tools and information/data review.
• Recommend an approach to case resolution and/or meeting needs by evaluating the member's benefit plan and available internal and external programs/services.
• Identify high-risk factors and service needs that may impact member outcomes and care planning components with appropriate referral to clinical case management or crisis intervention as appropriate.
• Coordinate and implement assigned care plan activities and monitor care plan progress.
• Enhancement of Medical Appropriateness and Quality of Care:
• Consult with case managers, supervisors, Medical Directors, and/or other health programs to overcome barriers to meeting goals and objectives using a holistic approach.
• Present cases at case conferences to obtain multidisciplinary review in order to achieve optimal outcomes.
• Identify and escalate quality of care issues through established channels.
• Utilize negotiation skills to secure appropriate options and services necessary to meet the member's benefits and/or healthcare needs.
• Utilize influencing/motivational interviewing skills to ensure maximum member engagement and promote lifestyle/behavior changes to achieve an optimum level of health.
• Provide coaching, information, and support to empower the member to make ongoing independent medical and/or healthy lifestyle choices.
• Help members actively and knowledgably participate with their provider in healthcare decision-making.
• Monitoring, Evaluation, and Documentation of Care:
• Utilize case management and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures.

• 1 year(s) in behavioral health, social services, or human services field.
• Willing and able to travel up to 50%-75% locally to meet members face to face.
• Must have reliable transportation.

• Computer literacy and demonstrated proficiency in navigating through internal/external computer systems.
• Proficiency in MS Office Suite applications, including Word and Excel, is strongly preferred.
• Case management and discharge planning experience preferred.
• Managed Care experience preferred.
• 1-year experience in Home and Community-Based Services (HCBS) waiver.

• Bachelor's degree or non-licensed master level clinician required, with either degree being in behavioral health or human services preferred (psychology, rehabilitation, social work, marriage and family therapy, counseling).

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