Healthcare Consultant – Care Management Associate

Published
June 17, 2022
Location
Atlanta, GA
Category
Job Type

Description

  • The role will be primarily managing the pdf files the field nurses upload - renaming, reorganizing, and linking into individual member records in our Dynamo software.
  • Provide comprehensive healthcare management to facilitate delivery of appropriate quality healthcare, promote cost effective outcomes and improve program/operational efficiency involving clinical issues.
  • The dedication of talented and caring health care professionals drives the delivery of high-quality, cost-effective products and services.
  • They make it possible for members to get the right health care treatment for their needs and for healthcare to keep its competitive edge.
  • Provide comprehensive healthcare management to facilitate delivery of appropriate quality healthcare, promote cost effective outcomes and improve program/operational efficiency involving clinical issues.
  • Support comprehensive coordination of medical services including Care Team intake, screening, and supporting the implementation of care plans to promote effective utilization of healthcare services. Promotes/supports quality effectiveness of Healthcare Services.
  • Responsible for initial review and triage of Care Team tasks.
  • Identifies principal reason for admission, facility, and member product to correctly apply intervention assessment tools.
  • Screens patients using targeted intervention business rules and processes to identify needed medical services, make appropriate referrals to medical services staff and coordinate the required services in accordance with the benefit plan.
  • Monitors non-targeted cases for entry of appropriate discharge date and disposition.
  • Identifies and refers outlier cases (e.g., Length of Stay) to clinical staff.
  • Identifies triggers for referral into Healthcare's Case Management, Disease Management, Mixed Services, and other Specialty Programs.
  • Utilizes eTIME and other Healthcare systems to build, research and enter member information, as needed.
  • Support the Development and Implementation of Care Plans.
  • Coordinates and arranges for health care service delivery under the direction of nurse or medical director in the most appropriate setting at the most appropriate.
  • Expense by identifying opportunities for the patient to utilize participating providers and services.
  • Promotes communication, both internally and externally to enhance effectiveness of medical management services (e.g., health care providers, and health care team members respectively)
  • Performs non-medical research pertinent to the establishment, maintenance, and closure of open cases.
  • Provides support services to team members by answering telephone calls, taking messages, researching information, and assisting in solving problems.
  • Adheres to Compliance with PM Policies and Regulatory Standards.
  • Maintains accurate and complete documentation of required information.
  • that meets risk management, regulatory, and accreditation requirements.
  • Protects the confidentiality of member information and adheres to company policies regarding confidentiality.
  • May assist in the research and resolution of claims payment issues.
  • Supports the administration of the hospital care, case management and quality management processes in compliance with various laws and regulations, URAQ and/or NCQA standards, Case Management Society of America (CMSA) standards where applicable, while adhering to company policy and procedures.
  • Determines medical necessity/ appropriateness.
  • Facilitates optimal outcomes.
  • Identifies and follow through with continuous quality/ compliance opportunities. May also include identification of aberrances and initiation of corrective action.
  • Educates/ empowers customers to ensure compliance, satisfaction and promote patient advocacy
  • Optimize total costs.
  • Implementation and evaluation of policy based on usage and program directives.
  • Educate/empower colleagues at all levels to enable decision making at most appropriate level.

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