|Open Positions: 7
Location: Lee’s Summit, MO (200 Building)
Performs essential functions of care management for identified and assigned member population according to HIPAA guidelines. Manages a specified caseload; coordinating health care benefits, providing education and facilitating member access to care in a timely and cost-effective manner. Collaborates and communicates with member, family, and health team to promote wellness and member autonomy, while ensuring access to appropriate services across the healthcare continuum and maximizing member benefits. Serves as clinical advocate for members and liaison with other departments and external health care team. Uses claims processing and care management software to look up member information, document contacts, and track member progress. Functions as a peer leader in the Care Management Career Ladder program.
• Evaluates information regarding prospective care management members referred by providers utilization review vendors, members Customer Service Claims staff or data sources to determine whether medical care management intervention is necessary to meet the member’s needs.
• Manages a participant caseload including communication with participants, providers and family or authorized representatives’. Reviews member claims histories and identifies intervention opportunities. Contacts and interviews members to conduct a baseline assessment, assess self-care ability, assess knowledge and adherence deficits.
• Collaborates with primary care physician and other treating professionals as appropriate. Authorizes initiation of care management services and specialized program services for members and specific populations, and develops interventions designed to meet member or population desired outcomes. Educates members about accessing services, in-network use, national guidelines for care, and self-management skills and strategies.
• Employs engagement techniques to build relationships with members and their authorized representatives. Encourages participants to participate in their health care decisions and assists member with researching treatment options in order to communicate effectively with providers and to make informed decisions.
• Provides direction and assistance to Cost Utilization Specialists regarding benefit approvals and denials. Notifies Cost Utilization Specialists of participant’s needs including the need for special educational mailings, reminder calls, satisfaction surveys, incentives or any additional service needs according to specific program guidelines.
• Collaborates with the GEHA Medical Director regarding complex benefit decisions and obtains medical approval of denials per department guidelines. Processes benefit determinations according to company policies.
• Facilitates appropriate use of resources and coordinates necessary services to improve health status and impact the cost of care. Identifies member needs for and refers to appropriate internal and external programs, as appropriate. Redirects members and providers to in-network facilities when available. Negotiates rates for those services provided out of the network, as well as high dollar services provided in network, when appropriate.
• Researches new medical technologies and standards: reviews information from university hospital systems, the National Institutes of Health, and local community resources and approved websites. Encourages member and family empowerment through education and use of reliable resources.
• Monitors and evaluates member progress: evaluates member-response to interventions and refines action plan to produce desired outcomes. Identifies complex care management issues and discusses possible solutions with management. Assesses program/project effectiveness.
• Uses claims and care management software to document interactions and interventions with members, vendors, and providers. Maintains case information in the member’s clinical records to promote care coordination and accurate and timely claims payment. Identifies cost-savings activities and documents in care management software, including rationale for care.
• Works collaboratively with peers and management to identify department opportunities for improvement using member feedback, clinical or program experience, and available data. Actively supports initiatives specific to improvement of department clinical and financial outcomes.
• Provides ongoing direction and support to internal customers regarding Care Management programs, processes, and benefit coverage.
• Takes accountability for obtaining and maintaining nursing licensure in all states as required. Takes accountability for the identification of personal educational needs and works with management to develop a plan for obtaining the necessary training.
• Participates in the Care Management Career Ladder program and meets requirements of Clinician I per published criteria within established timeframes.
• Performs other duties as assigned.
Requires a Bachelor’s degree, current RN license in good standing in state of residence and must be eligible for licensure in all 50 US states. Additional years of qualifying work experience may be considered in lieu of Bachelor’s degree.
Requires two years of recent RN care management experience in a hospital or managed care setting, such as a health insurance environment. Requires at least three years of nursing experience in a clinical setting. Requires current knowledge of clinical standards of care and disease processes. Requires critical thinking skills, effective verbal and written communications skills to consult with physicians and providers, and demonstrated ability to negotiate costs. Requires basic computer skills and knowledge of medical information systems. Required to coordinate the demands of cost control and service responsiveness for members in catastrophic medical situations. Candidate is required to disclose all adverse actions imposed by any State Board of Nursing.
*Wound care experience with a focus on skin grafts
*Negative pressure wound therapy
*Asthma care experience
GEHA is an Equal Opportunity Employer. GEHA will not discriminate against employees or applicants because they have inquired about, discussed, or disclosed their compensation or the compensation of another employee or applicant.
Our company's corporate headquarters is located in Lee's Summit near Douglas Rd and I-470 with a total of five locations in the Kansas City metropolitan area.