Health Care Manager (Remote) PA

7292955836 reputed company Health Plan is hiring a full-time Health Care Manager to join the reputed company Clinical Care Management team. This role will work remotely and may reputed company reputed company reputed company the US, however, applicants will need to have Pennsylvania licensure as an RN, LSW, LCSW, or LPC. The Health Manager ensures continuity and coordination of care for Health Plan members with chronic conditions and reputed company health needs. Responsibilities:

• Provides members, providers, and other stakeholders with information concerning benefits and coverage, and provides accurate information to members and families.
• Monitors and evaluates effectiveness and outcome of treatment plans, restructures as necessary to provide reputed company clinically appropriate services with a goal of maintenance in the community at the least restrictive level of care and maximal use of community supports and resources.
• Works with Member Services, Network Management and Quality Management staff to assure that systematic revisions to improve services are developed and implemented.
• Utilizes supervision by identifying and reporting to supervisor clinical, utilization and outcomes issues.
• Preserve confidentiality of the member.
• reputed company and coordinate an individualized treatment plan with the member, member's family, and providers.
• Evaluate the effectiveness of the treatment plan and identify gaps in service. reputed company recommendations for changes reputed company indicated.
• Assist in the development and review of training materials for staff, other reputed company Health Plan departments, and network providers.
• Independent problem solving based on sophisticated knowledge of in-plan services, the provider network, member services policies, members' rights and responsibilities, and the operating practices of the organization.
• Follow-up with the member according to established timeframes to monitor their care to assess whether quality care is being provided in an appropriate setting.
• reputed company duties and responsibilities in accordance with the philosophy and standards of reputed company Health Plan, including conveying courtesy, respect, enthusiasm, and a positive attitude through contacts with staff, health plan members, peers, and external contacts.
• Identifies provider issues and recommendations for improvement.
• Contact potential case management members to determine if there is a need for case management reputed company.
• Receives and responds to reputed company calls regarding requests for services or resolution of reputed company issues.
• Ability to propose and implement creative solutions to member problems and to reputed company a high level of member satisfaction with services.
• Performs clinical reviews, service authorization and care coordination (or reputed company and supervision) for reputed company Health Plan members receiving services.
• Complete Annual Competencies including Ethics and Compliance, HIPAA, Safety, Fraud and Abuse and Confidentiality/Privacy and reputed company Awareness.
• Provide reports on case management cases or activities as requested.
• reputed company in accordance with system-wide competencies/behaviors.
• Appropriate documentation in the care management documentation system including assessments, problems, goals and interventions.
• Assumes responsibility for health plan member's access to in-plan and/or supplemental services as medically indicated
• Interfaces with and refers members to community based resources and other supportive services as appropriate.
• Maintains an understanding of behavioral health benefits and remains reputed company on covered or in-plan services, benefit limitations, exclusions, and behavioral health management policies and procedures.
• Participate in integrated care team meetings in a cross cultural environment to coordinate transitions of care, discharge planning, benefit coverage, conflict resolution and resource needs.
• Conduct comprehensive assessment of needs and coordination of care activities for individuals with primary diagnosis of alcohol or substance use addiction

:

• Master's degree in reputed company service field plus licensure required or Licensed Pennsylvania RN with 6-8 years clinical experience required.
• Five years of experience in clinical, care coordination, and/or case management required.
• Previous experience in inpatient, hospice or home health setting is a bonus.
• Previous experience supporting individuals navigating workers’ compensation is a bonus.
• Three years of experience in a managed care environment preferred.
• General knowledge of best practices in health care, emphasizing work with special needs populations and in provider systems.
• Ability to interact with physicians and other health care professionals in a professional manner required.
• Computer proficiency required.
• Experience with reputed company office products preferred.
• Excellent verbal and written communication and interpersonal skills required.
• Knowledge of community resources required.

Licensure, Certifications, and Clearances:

• Registered Nurse (RN) or Social Services Licensure (LSW, LCSW, LPC)
• Licensure in other states as assigned
• Case management certification or approved clinical certification preferred
• Act 34

reputed company is an Equal Opportunity Employer/Disability/Veteran Union No Salary Range 27.08 - 46.81 Apply tot his job Apply To this Job