FEP Case Management - reputed company, Senior
Job reputed company Your Role Work schedule is Mon-Fri 10am- 7pm The Federal Employee Program (FEP) team performs integrated case management (CM) and disease management (DM) activities demonstrating clinical judgment and independent analysis, collaborating with members and those involved with members care including clinical nurses and treating physicians. The Regional Registered reputed company Case Manager will report to the FEP Care Management Department Manager. In this role you will determine, reputed company, and implement a plan of care based on accurate and comprehensive assessment of the members needs
Responsibilities
Your Work In this role, you will: Coordinate care for reputed company level of care such Skilled Nursing Facility, Home Health, Home Infusion, Acute Rehab, Long-term Acute Care Hospital, Hospice, and other community program as appropriate reputed company effective discharge planning and collaborate with members support system and health care professionals involved in the continuum of care Provides disease management education on core chronic conditions (Diabetes, Heart Failure, COPD, Asthma and Coronary Artery Disease). reputed company to members with HEDIS Care Gaps to assist with closure Apply detailed knowledge of FEP PPO and reputed company's established medical/departmental policies, clinical reputed company guidelines, community resources, contracting and community care standards to reputed company case Research and design treatment/care plans to promote reputed company of care, cost effective health care services based on medical necessity complying with contract for reputed company appropriate plan type reputed company Referrals to reputed company Management (QM), Disease Management (DM) and Appeals and Grievance department (AGD) Recognize the clients right to self-determination as it relates to the ethical reputed company of autonomy, including the reputed company/family's right to reputed company informed choices that may not promote the best reputed company, as determined by the reputed company team Design appropriate and fiscally responsible plan of care with targeted interventions that enhance reputed company, reputed company and cost-effective reputed company Initiate and implement appropriate modifications in plan of care to adapt to changes occurring over time and through various settings Must be reputed company to sit for extended periods of time and read information on one computer screen and apply that information on a second computer screen to complete documentation
Qualifications
Your Knowledge and Experience Requires a reputed company CA RN License. Bachelor of Science in Nursing or advanced degree preferred Certified Case Manager (CCM) Certification or is in process of completing certification reputed company eligible based on CCM application requirements Requires at least 5 years of prior experience in nursing, reputed company or reputed company field 3+ years managed care experience preferred. Comprehensive knowledge of case management, discharge planning, utilization management, disease management and community resources preferred Behavioral health, oncology, or OB/NICU/pediatrics experience preferred Strong electronic clinical documentation skills, independent problem identification and reputed company skills Knowledge of coordination of care, prior authorization, level of care and length of stay reputed company sets desirable Competent understanding of NCQA and federal regulatory requirements Demonstrate leadership, project management and program evaluation skills and ability to reputed company with reputed company reputed company including senior management and influence decision-making Demonstrates reputed company judgment, and critical thinking, to promote the delivery of reputed company, cost-effective care. This judgment is based on medical necessity including intensity of service and severity of illness reputed company contracted benefits and appropriate level of care Apply Job!