Where compassion meets innovation and technology and our employees are family.

General Purpose of Job:

Case Management is a collaborative practice that assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet the member’s  health and human service’s needs. It is characterized by advocacy, communication and resource management and promotes quality and cost-effective interventions and outcomes. The Case Manager facilitates clinically appropriate and fiscally responsible patient care through communication with the treating physicians, and all other members of the health care team. The Case Management Process is centered on a client/support system. It is holistic in its coverage of the client’s situation and addresses medical, physical, emotional, financial, psychosocial, behavioral, emotional, and other needs, as well as that of the member’s support system. The case manager screens the member to identify the need for case-managed services by conducting a series of assessment activities including: 1) reviewing the member’s current and past health and medical history, vocational history, and functional status 2) stratifying the member’s risk (low, moderate, or high) after a comprehensive assessment and 3) identifying the member’s specific or chief complaint(s), including actual and potential problems. The Case Management Process consists of nine phases through which Case Managers provide care to Driscoll Health Plan members: Screening, Assessing, Stratifying Risk, Planning, implementing (Care Coordination/Planning), Following Up, Transitioning, Communicating Post Transition, and Evaluating. The overall process is iterative and cyclical, its phases being revisited as necessary until the desired outcomes are achieved and the members’ interests are met.

Essential Duties and Responsibilities:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.  The requirements listed below are representative of the knowledge, skill, and/or ability required.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. This job description is not intended to be all-inclusive; employees will perform other reasonably related business duties as assigned by the Director of Case and Disease Management as required.

General Responsibilities:

• Maintains utmost level of confidentiality at all times.
• Adheres to Health System and Health Plan policies and procedures.
• Demonstrates business practices and personal actions that are ethical and adhere to corporate compliance and integrity guidelines. 

Case Manager’s Responsibilities:

Knowledge:

• Be knowledgeable in Medicaid criteria/guidelines.
• Be knowledgeable about managed care contracts/guidelines.
• Be knowledgeable of data-driven decision-making tools and their use.
• A working knowledge of various reimbursement mechanisms, including third party requirements.
• Current working and demonstrated knowledge of various criteria sets (i.e., InterQual) preferred.

Responsibilities:

• Communicating with members and their support systems, as well as other healthcare providers.
• Apply plan benefits consistently for each line of business.
• Provides ongoing oversight, availability and monitoring of non-clinical staff activities.
• Identify members with special health care needs for possible disease management programs available within the plan.
• Negotiate with vendors when necessary for services/equipment.
• Ensure appropriate referrals/authorizations to agencies, assistance programs, physicians and other healthcare related programs are completed within established turnaround times.
• Coordinate appropriate Community/health agency referrals.
• Report, as appropriate, potential adult/elder/child abuse cases to appropriate agency and coordinate with Driscoll Health Plan (DHP) Social Workers.
• Collaborate with physicians, social workers, nurses, and other multidisciplinary team members as appropriate to obtain optimal outcomes for members.
• Assess a member’s needs and social support network.
• Complete documentation about a member’s case management plan of care, progress toward meeting care goals, outcomes, care reports, etc. Managing a member with one or multiple chronic illnesses such as heart failure, diabetes, asthma, ESRD, bipolar disorder, and dual diagnosis.
• Complete documentation about a member’s case management plan of care, progress toward meeting care goals, outcomes, care reports, etc. while managing members with Early Childhood Intervention needs.
• Conducting a case conference to resolve disagreement and/or clarify a plan of care as needed.
• Serve as the expert resource regarding reimbursement and clinical practice issues.
• Participate in health plan’s performance improvement activities.
• Accepts other assignments from management as requested and comply with basic management principles of delegation.
• Communicates with management regarding status of current workload and turn-around-time discrepancies as necessary. Must obtain approval from manager or designee prior to any distribution of workload.
• Adhere to departmental and health plan policies.
• Provide availability to non-clinical staff activities.
• Participate in timely completion of preauthorization activities for outpatient services.
• Collaborate with hospital case managers to assure that impediments to safe discharge are recognized immediately and corrective action strategies are developed to ensure patient safety and maximize positive outcomes for the member and the organization.
• Complete prospective review for discharge planning and prior authorizations for outpatient surgical procedures in accordance with plan-approved evidenced based criteria, guidelines, and policies.

Education and/or Experience:

• One year of acute inpatient case management or managed care case/utilization management experience preferred.
• A minimum of three (3) years prior clinical experience.
• Graduate of an accredited school of Nursing.
• Must have a current valid Registered Nursing licensure in the State of Texas without restrictions

Certificates, Licenses, Registrations:

• Must have a current, active, and unrestricted Registered Nursing Licensure in the state of Texas.  
• Certification in Case Management or Managed Care preferred or strongly preferred to be obtained within two years of employment. Delete category if not applicable.