Case Manager Jobs in Ohio

Job Title: Complex Case Manager Company: Molina Healthcare Location: Columbus, OH Description: POSITION SUMMARY (Briefly describe the basic purpose of this position).  Registered Nurse responsible for the proactive identification, assessment, planning, implementation, coordination, monitoring and evaluation of case management services for the health plan membership.  Provides case management services to members with chronic or complex conditions. Authorizes home care, home infusion, physical therapy, occupational therapy, SNF etc. as appropriate to the case management plan.  Performs job in accordance with accrediting and regulatory guidelines and evidenced based practice. Adheres to the company’s/department’s confidentiality and HIPAA compliance programs.  Adheres to the company’s/department’s fraud and abuse prevention/detection policies and programs. Note: The information in this position description indicates the general nature and level of work performed by employees within this classification. It is not designed to be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of employees assigned to this job.REQUIRED SKILLS AND QUALIFICATIONS Education:Registered Nurse/Bachelor’s Degree PreferredExperience:3 –plus years clinical experience required2-plus years UM/CM experience requiredManaged Care experience preferredKnowledge of applicable state, federal and third party regulations and standards preferredPrevious Medicaid and/or government program experience preferredLicensure/Certification:Valid State of Michigan RN License requiredCase Manager Certification preferred/required for Level II PRINCIPLE ACCOUNTABILITIES Excellent verbal and written communication skillsProficiency with PC-based computer systems & software,  ability to learn new software productsExcellent organizational skillsVery strong analytical skillsAdditional Skills and Knowledge: DEPARTMENT/STATE SPECIFIC JOB FUNCTIONS Proactively identifies members that may qualify for potential case management services. Conducts assessment of member needs by collecting in-depth information from Molina’s information system, the member, member’s family/caregiver, hospital staff, physicians and other providers. Identifies, assesses and manages medical cases per established criteria.  ·         Proactively identifies members for participation in the case management program through claims information, pharmacy information, hospital admission information, provider referral, internal staff referral or member/caregiver referral. ·         Assesses member utilizing evidenced based or general assessment tools. Assessment occurs via telephone or in person as appropriate.·         Develops all letters/correspondence for members, PCP’s and ancillary providers regarding Molina’s case management program.·         Maintains appropriate documentation of all assessment information and correspondence mailed to members and providers. Develops and implements a case management plan to address the member’s individual needs as identified in the assessment process in collaboration with the member, caregiver, physician or other appropriate healthcare professionals. ·         Documents the case management care plan in Molina’s information system, including identified problems, goals, interventions and barriers to meeting goals. ·         Documents using Assessment, Plan, Implementation and Evaluation (A.P.I.E.) format, documentation will be specific, detailed and concise.·         Implements specific case management interventions to achieve both short and long term goals including the coordination and authorization of necessary services.·         Coordinates health services within the scope of available benefits or refers to appropriate community resources for services that are not covered.·         Requests clinical documentation to support the need for services that require authorization. ·         Refers to appropriate services based upon member needs including community agencies, ancillary providers, physicians and social workers.·        Maintains regular communication with state agencies, healthcare organizations, individuals and support systems to promote efficient and well-coordinated quality care. Performs ongoing monitoring of the plan of care to evaluate the plan’s effectiveness. Documents plan progress in Molina’s information system. Evaluates effectiveness of the plan and modifies as appropriate to reach optimal outcomes. Measures the effectiveness of interventions to determine case management outcomes. Participates in staff meetings and other appropriate meetings to discuss member care. Is prepared to discuss open cases and collaborate with the multidisciplinary team on case management interventions. Participates in the development of criteria or clinical pathways relevant to clinical specialty. Develops monthly reports on case activity and outcome analysis. Establishes and maintains a professional rapport with providers, members and internal customers. AA   Ability to handle difficult people and situations with diplomacy and tact. Participates in appropriate case management conferences to continue to enhance skills/abilities and promote professional growth. Demonstrates dependability and reliability Complies with required workplace safety standards. Perform other duties as assigned.