Case Manager, PPO - 26-126

PriMed Management Consulting•Sacramento, CA

About The Position

The Case Manager, PPO carries out case management activities for PPO members identified through data or by a health plan and referred to Hill Physicians Medical Group. Case management is a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates options and services to meet members’ health and human service needs. It emphasizes advocacy, communication, and resource management to promote quality, cost-effective interventions and outcomes, guided by nationally recognized case management standards and principles. All contacts are telephonic.

Requirements

At least three years of clinical nursing experience in an area such as medical/surgical, critical care, home health, or skilled nursing.
At least two years of experience in case management, behavioral health, utilization management, discharge planning, or quality improvement in a managed care setting.
Experience with managed care delivery, including IPA networks and Medicare.
Strong organizational skills and ability to meet expected and unexpected time frames.
Excellent verbal and written communication skills.
Ability to coordinate effectively with members, providers, office staff, health plans, internal departments, community resources, and peers.
Ability to work independently with self-initiative and discipline.
Knowledge of ICD-9 and/or CPT coding.
Working knowledge of personal computers.
A.S. degree.
Unrestricted California Registered Nurse licensure.

Nice To Haves

PPO experience.
Certification in case management.

Responsibilities

Collaborate with health plan care and disease management programs to maximize quality and manage costs for at-risk members.
Assess members’ physical and psychosocial needs and barriers, and develop care plans.
Support and encourage members to use participating health plan providers.
Develop and implement interventions to resolve barriers and coordinate care, helping members achieve goals with physician guidance and supervision.
Document assessments, care plans, interventions, and other care-coordination activity in Epic.
Maintain member privacy, safety, confidentiality, and advocacy while following ethical, legal, regulatory, and accreditation standards.
Maintain department procedures and policy standards, including turnaround-time requirements.
Support the interdisciplinary team approach to promote effective resource use and quality, cost-effective outcomes.
Coordinate internal and external resources for individual members.
Maintain and update a community resource database.
Document case management activities in the HPMG case management online system.
Issue letters of explanation in accordance with department policy.
Attend and participate in in-service programs and conferences that support case management practice.
Perform other duties as assigned.