Houston, United States
about 1 year ago
Strictly telephonic, office-based role. The case manager would be an LVN who is following up with the customer after the care plan is developed. Location is Address: 2800 N Loop West Houston, TX 77092
Responsible for coordinating the delivery of cost-effective, quality -based health care services for health plan customers by development and implementation of alternative treatment plans that address individual needs of the customer, their benefit plan, and community resources. Plans, implements, and evaluates appropriate health care services in conjunction with the physician treatment plan. Utilizes clinical skills to assess, plan, implement, coordinates, monitor and evaluates options and services in order to facilitate appropriate healthcare outcomes for customers. Ensures that case management program objectives are met by evaluating the effectiveness of alternative care services and that cost effective, quality of care is maintained. Provides clinical assessments, health education, and utilization management to customers. Performs community visits or telephonic outreach to customers that have been identified for case management. Nurse Case Managers also focus on risk identification, outreach, developing and implement care plans, follow ups, and assist with coordination of benefits when needed.
Identifies high-risk/high-cost patients for possible case management intervention.
Interfaces with providers of medical services and equipment to facilitate effective communication, referrals, development of discharge planning, and alternative treatment plan development. Identifies customer needs, coordinates and support planned and unplanned transitions and post discharge follow up calls which may include primary care physician and specialist appointment scheduling
Initiates contact with patient/family, physician, and health care providers/suppliers to discuss the alternative treatment plan. Documents all customer and provider contact, clinical notes, short term, long term and prioritize goals and revisions to the individual care plan in the integrated care management system
Collaborates with the attending physician to achieve identified patient outcomes. Develop and implement individual care plans with customer Communicate care plan with customer and physician
Extends, revises or closes care plan goals as is appropriate. Refers questionable case management cases or requests to the Medical Director
Communicates in writing to the appropriate parties regarding case management decisions. Communicates denial decisions to all appropriate parties following established guidelines, when dealing with a denied authorizations such as, but not limited to, out-of-network referrals
Evaluates each case for quality of care, documents quality issues and appropriately refers cases with questionable quality of care to the Manager of Quality Assurance. Attend and participate in weekly Complete Health Team rounds Perform telephonic outreach
Communicates with all departments to resolve issues or document trends.
Understands and follows administrative guidelines (policy and procedure) of the unit.
Attends and actively participates in staff meetings.
Other Duties as assigned.