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Welcome to a team of caring and passionate people who work each day to meet the needs of our members and clients. At Health Benefits (a subsidiary of Health Care Service Corporation), you will be part of an organization committed to offering custom services to self-funded health benefits plans that manage costs – without compromising benefits – by offering innovative solutions, flexibility, transparency and customer support. This is an exciting time to join our team and enhance our culture that emphasizes caring, diversity and inclusion, mutual respect, collaboration and service to our communities.
Position Overview: Our Case Management team is expanding and we are hiring Case Managers that will promote and support the improvement of health outcomes for members while providing assistance during periods of illness and injury. In this role, you will assess, plan, implement, coordinate, monitor and evaluate options and services to meet members’ individual healthcare needs for a defined case load. You will promote high quality, cost-effective outcomes to meet members’ needs throughout the continuum of care. You will also work with a tenured, talented and caring team of Case Managers. Ideally, you’re a strong communicator, able to work well independently at times but, you are also a champion of collaboration both with internal associates and external stakeholders.
Summary: The Case Manager acts as the liaison between a patient, the primary care physician and other providers in the healthcare community. The Case Manager assesses, plans, implements, coordinates, monitors, and evaluates the options.
Responsibilities:
- Identifies potential candidates for individual case management services and executes the screening and case management process.
- Implements, coordinates and monitors efficient care for targeted patients using a variety of healthcare delivery systems as appropriate. The delivery systems can include acute, long-term care, subacute, skilled nursing and rehabilitation settings, as well as, surgery centers, home health agencies and other settings.
- Works closely with patients at the time of enrollment to identify those who are currently high cost/high utilizers or at-risk for high cost/utilization.
- Assesses the new patient’s situation, provides information about healthcare options, serves as a guide and advisor to the patient and his/her family, and establishes a long-term relationship with the primary care physician and patient.
- Works with the primary care physician to establish protocols for routine and preventive care for the patients, which reflect accepted standards of care.
- Researches and selects care options as appropriate. May make recommendations of alternative medical care and alternative non-medical services for approval and authorization by the primary care physician.
- Supports utilization management decisions with nationally recognized medical management criteria.
- Performs prospective, concurrent and retrospective reviews to ensure the medical necessity and appropriateness of hospital admissions and continued stays utilizing nationally recognized medical management criteria when assigned.
- Performs certification of outpatient surgeries and treatments when assigned.
- Performs prospective, concurrent and retrospective review of ancillary services when assigned.
- Performs discharge planning coordination.
- Refers all cases that do not meet applicable criteria or have potential quality of care issues to the Physician Advisor.
- Maintains a comprehensive, computerized medical and social history for assigned patients. Information will be used for such activities as patient assessment, care planning, patient/care evaluation, case tracking, and risk predictions, as well as cost analysis.
- Works to facilitate patient compliance and ensure continuity of care per the team’s “care plan” through the patient’s tenure in the program.
- Regularly assesses and evaluates the effectiveness and quality of health care services and treatments provided to patients by analyzing outcomes and reports.
- Provides individual client focused reports accentuating Case Management activity and outcome.
- Establishes a network of community resources necessary for providing appropriate care to patients.
- Serves as a program advocate by conducting training sessions, offering presentations, visiting providers, etc.
- Negotiates rates with vendors according to company policies and procedures.
- Facilitates the flow of claims through the Healthcare Management Department.
- Maintains a focus on timely customer service for internal and external customers.
- Provides input to the evaluation of the program’s overall effectiveness.
- Makes recommendations for system development from a user’s perspective.
- Assists with the orientation of new Healthcare Management personnel, offers assistance to co-workers and contributes to the ongoing networking of expertise with co-workers.
- Maintains active nursing license and continuing education requirements.
- Other duties as assigned.
Qualifications:
- Bachelor’s of Science in Nursing preferred.
- Active RN License required
- Current CCM certification or the ability to obtain within 18 months of hire if not currently active required.
- Minimum of 3 years of clinical care required.
- Case Management or Utilization Management experience preferred.
- Bilingual in Spanish a plus.
- Excellent time management, interpersonal, communication, documentation and customer service skills
- Ability to work in a busy, fast-paced environment both independently and collaboratively with the team, reprioritizing workload to meet customer and business needs
- Comfort with phone communications that facilitate engagement including the ability to effectively communicate with employees, employers, physicians, families in crisis, community agencies and all levels of leadership in an efficient yet empathetic manner
- Excellent critical thinking skills to deal with problems in varying situations and reach reasonable solutions, sometimes meaning using judgment and deviating from typical processes
- Proficient in the MS Suite, particularly in Word and Outlook
- Ability to read and interpret documents, criteria, instructions and policy and procedure manuals required.
Come join Health Benefits! Join a team that will not only utilize your current skills but will enhance them as well. Trustmark benefits include health/dental/vision, life insurance, FSA and HSA, 401(k) plan, Employee Assistance Program, Back-up Care for Children, Adults and Elders and many health and wellness initiatives.
The compensation range for this position is r role is $56,721 - $106,504. The salary offered will vary depending on your job-related skills, education, knowledge, and experience. This role aligns with an annual incentive bonus plan.
All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, sex, sexual orientation, sexual identity, age, veteran or disability.
Required Skills
Required Experience
