The Complex Case Manager II performs the collaborative process of assessment, planning, facilitation, care coordination, evaluation and advocacy for options and services to meet an individual member and their family's comprehensive health needs through communication and available resources to promote quality cost effective outcomes, in alignment with the standards of the Case Management Society of America (CMSA). The CareFirst complex case management process includes care coordination for the most acute, complex and catastrophic conditions, and collaboration with appropriate members of the external health care team and internal professionals with the CareFirst Hospital Transition of Care and PCMH programs. The Complex Case Manager II utilizes a full array of care coordination resources with the Total Cost & Care Improvement (TCCI) program drawing on clinical assessment and analytical thinking skills to actively and continuously facilitate a comprehensive treatment plan to stabilize the member and ensure appropriate services.
Principal Accountabilities: Under the general direction of the Supervisor of Case Management the incumbent's accountabilities include, but are not limited to the following (specific goals for Case Management Department are determined on an annual basis in accordance with divisional goals as outlined and approved the by the executive leadership team):
Current RN license with a minimum of 4 â“ 8 years of clinical experience in medical-surgical, community/home health care, case management, and equivalent experience reviewing patient medical care and services. and one or more of the following specialty fields
Special Needs/High Risk Pediatrics
Pediatric Oncology or Adult Oncology
High Risk Pregnancy
Complex Medical Illnesses (e.g MS, Lupus, Ulcerative Colitis)
Minimum of 2 years of Case Management experience or equivalent related work experience
In-depth knowledge of current standard of medical practice and insurance benefit structures to facilitate medical review decisions and interpret contract benefits and managed care guidelines.
A strong knowledge of Case Management process, standards, and understanding of managed care.
Detailed knowledge and competency in all types of medical necessity decisions, including inpatient care, sub-acute/skilled care, outpatient care, hospice care, and home health care.
A strong knowledge and expertise in case managing complex cases with minimal supervision.
Effective written and interpersonal communication skills to engage with members, healthcare professionals, and internal colleagues.
Ability to multitask, prioritize and maintain a dynamic personal organization system that allows for flexibility.
Ability to work independently and as part of a team.
Strong clinical documentation skills along with the ability to type on a computer keyboard with ease and speed.
Proficient in the use of web-based technology and Microsoft Office applications such as Word and Excel.
Ability to perform critical clinical analysis and build relationships with members/patients in order to effect change promote positive outcomes and empower member/family to be actively engaged in their treatment outcomes.
Proven experience in providing excellent customer service to external and internal customers.
Excellent analytical and problem solving skills in order to judge medical necessity and appropriateness of patient services and treatments on a case by case basis.
Must be able to effectively work in a fast paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time. Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
Full Job Description at https://carefirstcareers.ttcportals.com/jobs/2455860-case-manager-ii