Case Management Coordinator II

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Position Is Responsible For Performing Concurrent Review In Accordance With Accepted Department Criteria; Performing Discharge Planning And Identifying Alternate Treatment Programs That Provide Medically Necessary Potentially Cost Effective Services. Consulting With Physicians, Providers, Members, And Other Resources, As Appropriate, To Assess, Plan, Facilitate Implementation, Coordinate, Monitor, And Evaluate Options And Services Required To Meet An Individuals Health Needs, Using Communication And Available Resources To Promote Quality, Cost Effective Outcomes. Serving As Liaison To Physicians, And Members; Serving As Preceptor For Less Experienced Staff. This Position Will Perform Face To Face Visits In San Antonio And Provide Telephonic Support For All Other Locations. Ability And Willingness To Travel Within Assigned Location.

Concurrent review, discharge planning, and alternate treatment programs. Consult with physicians, hospital UR, Coordinators and hospital discharge planners to determine other resources and appropriate disposition of such cases. May do on-site review of cases. Perform additional ongoing functions to support the Medical Management Review, including more than one of the following. Apply accepted department criteria to first level reviews for medical necessity and appropriateness for all levels of care as required by group contract. Consult with physician, providers, members, and other resources, as appropriate, to assess, plan, facilitate implementation, coordinate, monitor, and evaluate options and services required to meet an individual’s health needs, using communication and available resources to promote quality, cost effective outcomes. Uses professional judgment and departmental guidelines to refer cases to case management and physician reviewers. Develop alternate plans and assist members/providers to navigate the health care system optimizing benefits. Refer care options to network providers. Assess cases for quality of care and refer cases to the physician advisors for review and follow up. Cooperate with other members of the department and interfacing departments as a team to decrease costs, coordinate benefits, and provider services, and quality to subscribers. Facilitate second level review of cases not meeting medical necessity guidelines. Participate as preceptor for orientation of new employees. Maintain and enhance knowledge of clinical nursing and regulatory standards by attending seminars, training sessions, etc. Perform Medical Management services for all lines of business, including FEP. Practice within the scope of licensure in accordance with URAC and NCQA accreditation standards. Communicate and interact effectively and professionally with co-workers, management, customers, etc. Comply with HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies and other applicable corporate and departmental policies. Maintain complete confidentiality of company business. Maintain communication with management regarding development within areas of assigned responsibilities and perform special projects as required or requested.