Highmark Health Case Mgr LTC - Gateway in Wilmington, Delaware
The Case Manager serves as the single point of contact for members to coordinate all of the member’s care needs across the various service delivery systems and community supports. This is a full time community based position requiring frequent travel within the assigned territory in DE. The Case Manager will travel to members’ homes, nursing facilities, and other community based setting for individuals enrolled in DSHP Plus LTSS.
Traveling to members’ homes, nursing facilities, and other community based settings in order to complete face to face needs assessments with subsequent telephonic contact with the member in accordance with state and national guidelines, policies, procedures, and protocols. Assessing, planning, coordinating, implementing and evaluating care for eligible members with chronic and complex health care, social service and custodial needs in a nursing facility or home and community-based care setting.
Coordinating care across the continuum of services and assisting members physical, behavioral, long term services and supports (LTSS), social, and psychosocial needs in the safest, least restrictive way possible while considering the most cost-effective way to address those needs. Facilitating authorization, coordination, continuity and appropriateness of care and services in community or HCBS
Facilitating transitions to alternate care settings such as hospital to home, nursing facility to community setting using an integrated care team to address the member’s specific needs. Educating members or caregivers regarding health care needs, available benefits, resources and services including available options for long term care community or facility-based service delivery. Providing education, resources, and assistance to help members achieve goals as outlined in their plan of care and to overcome obstacles to achieving optimal care in the least restrictive environment. Developing a plan of care in conjunction with members or caregivers to identify services to meet the member’s specific needs, and goals
Identifying resources needed for a fully integrated care coordination approach including facilitating referrals to special programs such as Disease/Chronic Condition Management, Behavioral Health, and Complex Case Management. Collaborating with the member's health care and service delivery team including the DSHP Plus LTSS Member Advocate, ICT, and discharge planners, to coordinate the care needs and community resources for the member in order to maintain the member in the least restrictive safe environment possible. Assisting members in developing, implementing and amending a back-up plan for gaps in provider coverage.
Ensuring approved support services are being provided as outlined in the plan of care. Evaluating the effectiveness of the service plan and making appropriate revisions as needed in accordance with per policy & procedures and state contractual requirements
Assisting members in overcoming obstacles to optimal care through connection with community resources, including communicating with providers and formulating an appropriate action plan. Documenting all case management services and intervention in the electronic health record.
Adhering to all company, State and Federal requirements related to privacy practices, HIPAA, and quality performance standards.
Performing other duties as assigned/requested.
Education, Licenses/Certifications, and Experience
Bachelor's degree in Social Work and
Minimum of 3 years’ experience in long-term care, home health, hospice, public health, or assisted living
Master’s degree in Social Work and
Minimum of 1 year experience in long-term care, home health, hospice, public health, or assisted living
Registered Nurse or Licensed Practical Nurse and
Minimum of 2 years’ experience in long-term care, home health, hospice, public health, or assisted living
One year in home clinical or case management experience
Medicare and Medicaid experience
Managed care experience
Knowledge, Skills and Abilities
Working flexible hours to meet member’s needs
Proficiency in PC-based word processing and database documentation (Word, Excel, Internet, Outlook)
Reliable transportation daily to be able to travel within assigned territory
Ability to meet regulatory deadlines.
Has a dedicated home work space used only for business purposes and is able to comply with all telecommuter policies.
Experience in geriatric special needs, behavioral health, home health
Understanding of the importance of cultural competency in addressing targeted populations.
Experience with electronic documentation system(s)
Experience with cost neutrality and budgeting
IV. SCOPE OF RESPONSIBILITY
Does this role supervise/manage other employees?
V. WORK ENVIRONMENT
Is Travel Required?
Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled