Scope:

The Chronic Condition Case Manager will have direct responsibility for managing an individual caseload using Complex and Chronic Condition Management constructs. This individual is expected to accurately service and satisfy customers by responding to customer inquiries, communicate benefit and healthcare questions/answers.

Education:

• Minimum of three years of clinical experience including at least two years of chronic disease management and patient teaching in any setting preferred.

Licensure/Certification Requirements:

• Registered Nurse (current unrestricted, in state of practice)

Experience:

• Minimum of three years of clinical experience including at least two years of chronic disease management and patient teaching in any setting preferred.

Requirements/Skills:

• Good keyboarding skills and computer literacy preferably with Microsoft Office applications and with internet.

• Must be fluent in English.

• Good organizational skills and time management

• Excellent verbal and written communication skills

• Ability to handle difficult situations tactfully and diplomatically.

• Effective problem solving and decision-making skills.

• Strong computer skills with proficiency in MS Office Suite products (Word, Excel, PowerPoint)

Duties and Responsibilities:

• The Chronic Condition Case Manager will practice within the scope of his/her licensure. Individual must speak fluent English with strong reading and writing abilities.

• Collect and document patient information to facilitate the initial assessment and formulation of an initial plan of care.

• Continuously gather, update and review information to include (but not limited to) collecting medical records, history, assessment information.

• Guide, coach and encourage the patient in following the plan of care. Instruct the participant regarding both short and long-term goals and offer guidance as to how to meet those goals. Document actions taken and interventions provided throughout the process.

• Collaborate with providers, payers, and participants to ensure that the participant has access to appropriate resources.

• Contact the payer to determine benefits and any constraints that may impact the plan of care.

• Contact providers and vendors to verify medical necessity of care or products that have been ordered.

• Make arrangements for quality care according to the needs of the participant, the physician’s orders and available benefits.

• Maintain a current up-to-date working knowledge of alternative treatments. If there are no benefits available for recommended alternative treatments, provide to the payer a cost-benefit analysis to demonstrate that extra-contractual services will enhance the participant’s medical condition and will be cost-effective to the benefit plan.

• Become familiar with community resources or other funding sources that will allow the participant to receive quality care and conserve health benefit dollars.

• Maintain documentation in the computer system. Complete all aspects of case in the computer.

• For fee-for-service clients:

• Prepare timely reports to the payer to summarize case actions, the results of those actions, and the continuing disease management plan.

• Maintain billing as appropriate in computer system.

• Adhere to standards of production goals.

• Maintain on-going contact with providers and participants to ensure that the participant’s needs are being met.

• As needed, negotiate with providers to maximize the medical benefits available to the participant. Make network referrals as appropriate.

• Take actions upon any awareness of non-medical issues which involve the participant’s safety or welfare and attempts to direct the participant or family to appropriate providers or community resources, or to personally notify appropriate authorities.

• Consult with the Director of Case Management on a regular basis. Keep the director informed regarding any complaints which may occur about disease management services or any issues which arise which the disease manager is not competent to handle or does not have the expertise to handle.

• Use good organizational skills to manage time and resources efficiently.

• Use effective writing style to organize information and thoughts and present them clearly and concisely in writing for prepared reports, correspondence, etc.

• Use effective teaching strategies during contacts with patients by telephone and in selecting appropriate educational materials. Use effective listening techniques to identify where the patient is in their stages of behavior change and respond appropriately.

• Seek opportunities for personal growth and development. Remain up to date on health and wellness topics as well as current treatment options for chronic medical conditions. Keep abreast of new trends and practices in the field of disease management

• Always maintain a professional attitude and approach using tact, courtesy, self-control, patience, loyalty, and discretion to work harmoniously with others. Maintain the ability to adapt to new situations and changing work responsibilities.

• Adhere to all department and company policies and procedures.

• Participate in onsite and offsite employee health fairs as needed. Provide individual or group teaching and/or facilitate support groups focused on a chronic disease topic.

• Participate in the Quality Management Program by adhering to all company policies and procedures and identifying opportunities for improvement to ensure quality services are rendered to clients and customers.

• The incumbent may be responsible for duties or responsibilities that are not listed in this job description. Duties and responsibilities may change at any time with or without notice.

Work Environment / Physical Demands: This position is in a typical office / home office environment which requires prolonged sitting in front of a computer. Requires hand-eye coordination and manual dexterity sufficient to operate standard office equipment including operation of standard computer and phone equipment.

The starting salary range for this position is $62,000 - $74,000 annually.

E.O.E.

KevYSGv7Ww