Healthcare - Care Manager II Care Manager II

Job Title: Care Review Processor I
Job Location: Dallas, TX (Remote)
Shift: 8:00 am-5:00 pm CT, 9:00 am-6:00 pm
Duration: 6 months (Possibility of extension)

Job Description:
Will these roles be fully remote?- yes
Are there any specific locations the candidates should live in? not necessarily, however counties we serve is a plus ie: Hidalgo, Harris, Tarrant, MERSA, Bexar, Dallas, Webb
What is the expected schedule (include dates/time/timezone)- usually Monday thru Friday 8 am to 5pm however may need to alternate at times to be able to locate members 7am to 4pm or 9 am to 6pm or ie: Saturday 8am to 12noon these time zones are CST for now
What are the day to day job duties?- reaching out to our members to close HEDIS Gaps, for example connect them to their PCP or document a BP reading in our Clinical software or connect them to resources that will help close their Care Gaps, wellness checks, flu vaccines, utilize community resources to assist with these gaps
Top Skills Required: Clinical terminology, bilingual is a major plus, understanding BP readings, Glucose Readings, Annual Wellness check ups
Required Education/Certification(s): Prefer RN or a LVN or a MSW
Required Years of Experience: at least 2 years’ experience

Summary:
Responsible for health care management and coordination of *** members in order to achieve optimal clinical, financial and quality of life outcomes.
Works with members to create and implement an integrated collaborative plan of care. Coordinates and monitors Client members progress and services to ensure consistent cost effective care that complies with Client policy and all state and federal regulations and guidelines.

Essential Functions:
Provides case management services to members with chronic or complex conditions including: o Proactively identifies members that may qualify for potential case management services. o Conducts assessment of member needs by collecting in-depth information from Clients information system, the member, members family/caregiver, hospital staff, physicians and other providers. o Identifies, assesses and manages members per established criteria.
Develops and implements a case management plan in collaboration with the member, caregiver, physician and/or other appropriate healthcare professionals to address the member needs.
Performs ongoing monitoring of the plan of care to evaluate effectiveness.
Documents care plan progress in Clients information system.
Evaluates effectiveness of the care plan and modifies as appropriate to reach optimal outcomes. o Measures the effectiveness of interventions to determine case management outcomes. Promotes integration of services for members including behavioral health and long term care to enhance the continuity of care for Client members.
Conducts face to face or home visits as required. Maintains department productivity and quality measures.
Manages and completes assigned work plan objectives and projects in a timely manner. Demonstrates dependability and reliability. Maintains effective team member relations.
Adheres to all documentation guidelines activities.
Attends regular staff meetings.
Participates in Interdisciplinary Care Team (ICT) meetings. Assists orientation and mentoring of new team members as appropriate.
Maintains professional relationships with provider community and internal and external customers.
Conducts self in a professional manner at all times. Maintains cooperative and effective workplace relationships and adheres to company Code of Conduct.
Participates in appropriate case management conferences to continue to enhance skills/abilities and promote professional growth. Complies with required workplace safety standards. Knowledge/Skills/Abilities:
Demonstrated ability to communicate, problem solve, and work effectively with people. Excellent organizational skill with the ability to manage multiple priorities. Work independently and handle multiple projects simultaneously.
Strong analytical skills. Knowledge of applicable state, and federal regulations. Knowledge of ICD-9, CPT coding and HCPC. Knowledge of SSI, Coordination of benefits, and Third Party Liability programs and integration.
Familiarity with NCQA standards, state/federal regulations and measurement techniques. In depth knowledge of CCA and/or other Case Management tools. Ability to take initiative and see tasks to completion.
Computer skills and experience with Microsoft Office Products.
Excellent verbal and written communication skills.
Ability to abide by Clients policies. Able to maintain regular attendance based upon agreed schedule. Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA). Skilled at establishing and maintaining positive and effective work relationships with coworkers, clients, members, providers and customers.

Required Education:
Bachelors Degree in Social Work or Health Education (a combination of experience and education will be considered in lieu of degree).

Required Experience:
2-4 years of clinical experience with Case Management experience.
Required Licensure/Certification: Must have valid drivers license with good driving record and be able to drive locally.