Proactive and predictive identification and appropriate recommendations for referrals to alternative health care programs ( e.g. , disease management, case management).
Conducts comprehensive health risk assessments (HRA) of Member’s clinical and psycho-social care needs and determines approaches to meeting needs either through the Altus ACE, the Member’s benefits plan or external programs and services. Assessments may be in person or telephonic.
Assists with teaching and coordinating medical and social referrals across the continuum of care including assistance with Medicaid recertification.
Develop and implement mutually agreed upon, person-centered care plans that include long-term and short term goals aimed at improving the Member’s overall health.
Evaluates and identifies health care service delivery using clinical knowledge to sequence services such that the Member receives care in the setting that best promotes quality and efficiency.
Reviews and approves all Member HRAs
Working with Medicaid and/or Medicare members who may be experiencing chronic and or complex biopsychosocial needs.
Qualifications/Requirements
Active RN license with the State of Texas
Strong customer service skills to coordinate service delivery including attention to Members, sensitivity to issues, proactive identification and resolution of issues to promote positive outcomes for Members.
Ability to effectively participate in a multi-disciplinary team including internal and external participants.
Familiarity with basic medical terminology and concepts used in care management
Effective communication, telephonic and organization skills.
Computer literacy in order to navigate through internal/external computer systems, including Excel and Microsoft Word.
Reliable transportation to travel to member homes or other locations within service delivery area
Education and Certification Preferred
Case Management certification preferred
Bilingual in Spanish preferred
3-5 years acute clinical/surgical experience
Previous case management experience, Managed care organization experience with Medicaid/Medicare and Duals or post-acute and/or Community care experience a plus.
Physical Demands: The employee must occasionally lift and/or move up to 25 pounds
All your information will be kept confidential according to EEO guidelines.
Reasonable Accommodations: Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the position.
