Details: Complex Case Manager II (Non-Remote) Location: West Houston, TX This is a Non-remote, Telephonic Registered Nurse (RN) position Position Summary Responsible for the assessment, planning implementation, coordination, monitoring, and evaluation of case management services. Duties & Responsibilities Identifies, assesses and manages medically catastrophic cases per established criteria. Coordinates case management activities with the primary care provider, UM staff, hospital discharge planner, social workers, public agencies, and other providers as required. Coordinates necessary services with participating ancillary service providers and public agencies as appropriate to ensure quality cost effective care for the member. Develops case management plan of care consistent with the sound medical and financial management. Includes assessment of health needs, individualized case management plans, implementation, monitoring and evaluation of case outcomes. Arranges for health care services within the scope of available benefits. Documents medical management within the Informacare system. Documentation includes assessments, plans of care, updates, contacts and planned tasks. Reviews and updates case management plans for continuity of care and facilitates plan modifications including barriers to goals and interventions. On a monthly basis, evaluates and revises acuity levels assigned to each case. Maintains system for monitoring all active cases on caseload. Maintains active revolving case management caseload of approximately 50 cases at varying acuity levels per Molina Healthcare, Inc. criteria. Maintains a cost analysis of services authorized for member. Contributes to monthly departmental Cost Savings Report. Maintains department quality standards, including inter-rater reliability (IRR) testing and quality review audit scores. Expectation is obtainment of score =90% for IRR and average of =90% for all quarterly review scores after 90 days of employment Performs other duties as assigned by Supervisor, including mentorship, assisting leadership in coordination of work, quality review, etc. Is involved in specialty case management programs that include Emergency Department High-Utilizer Program, Maternity Program, complex Case Management Program, Patient Review and Restriction Program. Involved in program development and process improvement activities. Attends meetings related to case management issues and Utilization Management Department issues such as Inpatient Census Hospital Review weekly, Estimated Length of Stay monthly and Case Management Team meetings. Performs inpatient/outpatient reviews on assigned members Performs admission, concurrent, discharge planning and retrospective reviews to obtain and document an accurate clinical assessment, and make medical necessity and appropriate level of care determinations within professional license scope of practice. Performs data entry (per policy/procedure) and utilizes the Inpatient Census Report to track, monitor and document member hospital utilization. Consults with Medical Director to discuss medical necessity, length of stay and appropriateness of care issues. Identifies and reports under and over utilization management issues, delays in service or treatment, and quality of care issues per policy/procedure. Is responsible for screening, assessment and coordination of care for members meeting protocols and criteria for Catastrophic and Targeted Case Management Programs. Utilizes clinical assessment skills and knowledge of patient care to make decisions regarding appropriateness or medical necessity of services, and determine which cases should be referred to the Medical Director for evaluation. Able to apply clinical criteria and guidelines to ensure appropriate administration of benefits and optimum medical outcomes based on the use of relevant InterQual criteria and Medicaid/Medicare guidelines. Initiates and coordinates discharge planning by ensuring the MHT member has access to services or equipment such as home health, durable medical equipment, and prescriptions based on member eligibility and benefits. Provides coverage for other case managers as needed Meets attendance guidelines per Molina Healthcare policy Knowledge, Skills and Abilities Knowledge of a variety of clinical areas of medical treatment. Perinatal preferred. Knowledge of hospital/patient care facilities, current practices, procedures, acceptable medical treatment and diagnoses; Skill to learn company policies and procedures as they relate to hospital authorization/denials, physician review, appeals, etc.; Skill to successfully apply established guidelines and regulations to specific and individual situations; Skill in both oral and written communications to ensure the accurate transferal of information and to build rapport that will ensure the trust, confidence and cooperation of others in a work situation; Skill in establishing and maintaining a variety of records necessary to provide complete information and documentation for relevant and appropriate medical determination; Skill to establish and maintain effective work relationships with those contacted in the performance of required duties. Proficiency with PC-based computer systems, ability to learn new information systems and software. Excellent organizational skills. Excellent verbal and written communication skills Ability to abide by Molina’s policies Maintain regular attendance based on agreed-upon schedule Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA) Ability to establish and maintain positive and effective work relationships with coworkers, clients, members, providers and customers Bilingual Spanish preferred Required Education Registered Nursing Degree required Preferred Education Bachelor’s Degree in Nursing preferred Case Management Certificate preferred Required Experience Minimum 2 years Medical Case Management experience. Minimum 1 year Public Health experience. Minimum 2 years critical care and/or med-surg experience. Knowledge of applicable state, federal and third party regulations and standards (Champus, Labor and Industry, SSI Program) Background in discharge planning and home health Required Licensure/Certification Valid Texas State Register Nursing license Capability of transporting self to various locations Must have a valid Texas Driver’s license; if using own vehicle, must have proof of insurance coverage that at least meets current State minimum requirements. Preferred Licensure/Certification: BSN preferred Certified Case Manager (CCM) Certification preferred Molina Healthcare is an equal opportunity employer (EOE). M/F/V/D
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