Detroit, MI, United States
Date published: 9-Jul-2018
• Utilizing a collaborative process, the case manager will assess, plan, implement, coordinate, monitor, evaluate and advocate the options and services required to meet an individual’s health needs, using communication and available resources to promote quality, cost effective outcomes. The case manager helps identify appropriate providers and facilities throughout the continuum of services while ensuring that available resources are being used in a timely and cost effective manner in order to obtain optimum value for both the client and the reimbursement source.
• Assessment - The case manager will collect in-depth information about a person’s situation and functioning to identify individual needs in order to develop a comprehensive case management plan that will address those needs.
• Planning - The case manager will determine specific objectives, goals and actions as identified through the assessment process. The treatment plan is developed in collaboration with the member/authorized representative, treating physician, medical consultant, and, if appropriate, the social worker and keeping all parties informed of the treatment plan progress. The treatment plan should be action oriented and time specific.
• Implementation - The case manager will execute specific intervention that will lead to accomplishing the goals established in the case management plan.
• Coordination - The case manager will organize, integrate and modify the resources necessary to accomplish the goals established in the case management plan. Identify and coordinate services so that the member’s health care needs are met across the continuum of care using the most effective means available.
• Monitoring - The case manager will gather sufficient information from all relevant sources in order to determine the effectiveness of the case management plan.
The case manager will act as the liaison between the member/authorized representative and the facility, provider, and/or BCBSM management team through regular contact and collaboration with the member and provider(s), contacting the member/authorized representative on a regular basis:
• Evaluation - At appropriate and repeated intervals, the case manager will determine the plan’s effectiveness in reaching desired outcomes and goals. This process might lead to a modification or change in the case management plan in its entirety or in any of its component parts.
• Advocate - The case manager will advocate on behalf of the member/authorized representative.
• Conducting a thorough and objective evaluation of the patient’s current status including physical, psychological, environmental, financial, and health status expectation.
• As a patient advocate, seek authorization for case management from the recipient of services (or designer)
• Assessing resource utilization and cost management; the diagnosis, past and present treatment; prognosis, goals (short and long term).
• Identifying opportunities for intervention.
• Assisting members in meeting and managing both health care and quality needs
• Setting goals and time frames for goals appropriate to the individual.
• Identifying quality of care and savings opportunities, negotiating with providers when needed, facilitating the use of appropriate extra-and-contractual benefits, and providing the member with information or links to community, state, and/or federal resources.
• Maintaining communications and collaborating with patient, family, physicians and health team members and payer representatives.
• Comparing the patient’s disease course to established pathways to determine variances and then intervene as indicated.
• Introducing, assessing, opening, managing, closing assigned cases with guidance from the POD leader and physician consultant.
• Routinely assessing patient’s status and progress; if progress is static or regressive, determines reason and proactively encourages appropriate adjustments in the care plan, providers and/or services to promote better outcomes.
• The case manager will document patient profile updates, discuss cases with POD leaders, and schedule case reviews with the physician consultants on a routine basis.
• Establishing measurable goals which promotes evaluation of the cost and quality outcomes of the care provider
• Reporting quantifiable impact, quality of care and/or quality of life improvements as measured against the case management goals
Education and/or Experience:
• Registered Nurse with current Michigan License required
• Nursing Diploma or Associates Degree in Nursing
• Bachelor’s degree in Nursing or related fields (preferred)
• CCM certification (preferred). If not certified upon hire, encouraged to become CCM certified within four (4) years of functioning in a case management role
• Certification in Chronic Care Professional (preferred)
• Two (2) years full time equivalent of direct clinical care to the consumer
• Two (2) to four (4) years of clinical experience preferably in Case Management or Home Health Care with a Medical/Surgical background
• One (1) to three (3) years of experience with BCBSM (preferred)
• Working knowledge of Case Management principles and procedures based on nationally recognized standards of Case Management