Full Time, Employee
Harrisburg, PA (remote)
The Case Manager is responsible for the coordination of case management services for members who meet established criteria, with an emphasis on promoting quality care and cost effective outcomes. The Case Manager uses a collaborative process to assess Member needs, review options for services and resources, develop and implement a plan of care, coordinate resources, monitor progress, evaluate Member status, discharge Members and fully document the individualized member case management process and outcome.
Using established criteria, analyzes and evaluates referrals for potential enrollment of candidates into the Case Management Program. Conducts assessments to obtain information for a participant-centered plan of care and determination of acuity level, functional status, activity level and self-management level. Obtains consent forms necessary for candidates accepted into the Case Management Program.
Uses a collaborative process and serves as a liaison between the participant, family, significant others, physician(s) and other members of the treatment team. Develops future-oriented goals and health actions that assist participants with the implementation of appropriate self-directed care decisions and support improvement in health and self-reliance. Advocates for members and families by helping them to coordinate care and navigate resources throughout the healthcare system.
Conducts all case management activities, including documentation, in accordance with established departmental policies and procedures. Complies with all Clinical Management and corporate policies and procedures. Complies with URAC, NCQA and CMSA standards for Case Management as well as NCQA, ERISA and Act 68.
Minimum of five years recent clinical experience. Recent managed care experience is preferred. Registered Nurse with an active Pennsylvania license. Certification as a Case Manager and recent managed care experience are preferred.