Highmark Health Clinical Care Coordinator-UM in Wilmington, Delaware

Description

JOB SUMMARY

This job works directly with providers in a variety of health care settings to appropriately identify members with chronic conditions and/or gaps in care that can be positively impacted related to quality and care costs. The incumbent's responsibilities could include working in a physician’s office, visiting physician practices on a routine basis, working within a hospital setting and/or assessing and coordinating member’s care within the member’s home. Helps members to coordinate care and navigate the healthcare system by recommending and/or implementing interventions related to the improvement of medical care and costs.

ESSENTIAL RESPONSIBILITIES

  • Conduct member-facing clinical assessments that address the health and wellness needs of members using a broad set of clinical and motivational interviewing skills with the goal of impacting members’ self-management skills and positive behavior changes which will ultimately positively impact member satisfaction and care costs.

  • Serve as a subject matter expert to both internal and external sources (e.g. providers, regulatory agencies, UM and policy.) to provide education, consultation and training when indicated.

  • Serve as a resource to guide, mentor and counsel others in regard to understanding the drivers of health care costs to improve member outcomes related to Plan benefits and resources.

  • Collaborate, coordinate and communicate with the member’s treating provider(s) in more complex clinical situations requiring clinical and psychosocial intervention.

  • Develop/implement case or condition-specific plans of care and/or intervention plan, as needed, that can become a part of the member’s EMR or medical record to establish short and long-term goals.

  • Establish a plan for regular contact ( face-to-face as often as possible) with each member and/or provider to monitor progress toward goals, provide additional education and evaluate the need for modification or change in the plan of care.

  • Proactively incorporate lifestyle improvement opportunities and preventive care into member interactions and coaching.

  • Collaborate with the appropriate individuals to offer solutions to refine and improve existing practices or participates in developing performance improvement processes that will enhance member outcomes and operational performance/excellence as well support all strategic initiatives including Health Care Reform and STARS initiatives.

  • Work with providers related to performance measures and activities to educate and influence the behavior of members and providers.

  • Ensure that all activities are documented and conducted in compliance with applicable business process requirements, regulatory requirements and accreditation standards that support all lines of business.

  • Other duties as assigned or requested.

QUALIFICATIONS

Required

  • Current PA RN license and/or additional states as required or current Social Work license

  • 4 years of any combination of clinical, case management and/or disease/condition management, provider operations and/or health insurance experience

  • Clearances as required by specific practice or hospital, as applicable

Substitutions

  • None

Preferred

  • Certification in Case Management (CCM)

  • BSN

  • 5 years of any combination of clinical, case management and/or disease/condition management, provider operations and/or health insurance experience

Skills

  • Ability to work in a virtual environment (e.g., provider offices, facilities and/or member’s homes); accomplishing and coordinating work remotely

  • Proficiency in MS Excel and enhanced data and statistical analysis skills

  • Excellent interpersonal/ consensus building skills as well as the ability to work with a variety of internal and external colleagues from all levels of an organization

  • Broad knowledge of the health care delivery system including an understanding of health care costs drivers

  • Excellent verbal and written communication skills including individual and/or group education/training

  • Experience working with the healthcare needs of diverse populations and understanding the importance of cultural competency in addressing targeted populations.

  • Self-directed; self-starter; ability to work successfully with indirect supervision and moderate autonomy

  • Excellent organizational, time management and project management skills

  • Ability to work in a fast paced, high visibility, high performing team environment that requires flexibility

  • Ability to travel locally and work flexible hours in a practice or facility-based settings

  • Ability to communicate effectively in more than one language, preferred

  • Experience working directly with physicians in provider practice settings, members in a home environment or hospital discharge processes.

SCOPE OF RESPONSIBILITY

Does this role supervise/manage other employees?

No

WORK ENVIRONMENT

Is Travel Required?

Yes

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

REQNUMBER: J116264

Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity