Provide comprehensive healthcare management services to facilitate appropriate healthcare treatment, effectively manage healthcare costs and improve healthcare program/operational efficiency involving clinical issues. Determines medical necessity/appropriateness Facilitates optimal outcomes Identifies and follow through with continuous quality/compliance opportunities. May also include identification of aberrance's and initiation of corrective action Educates/empowers customers to ensure compliance, satisfaction and promote patient advocacy Optimize total costs Implementation and evaluation of policy based on usage and program directives Educate/empower colleagues at all levels to enable decision making at most appropriate level.
Coordinates case management activities for Medicaid Long Term Care/Comprehensive Program enrollees. Utilizes critical thinking and judgment to collaborate and inform the case management process, in order to facilitate appropriate healthcare outcomes for members by providing care coordination, support and education for members through the use of care management tools and resources. Conducts comprehensive evaluation of Members using care management tools and information/data review. Coordinates and implements assigned care plan activities and monitors care plan progress. Conducts multidisciplinary review to achieve optimal outcomes. Identifies and escalates quality of care issues through established channels. Utilizes negotiation skills to secure appropriate options and services necessary to meet the member's benefits and/or healthcare needs. Utilizes influencing/motivational interviewing skills to ensure maximum member engagement and promote lifestyle/behavior changes to achieve optimum level of health. Provides coaching, information and support to empower the member to make ongoing independent medical and/or healthy lifestyle choices. Helps member actively and knowledgeably participate with their provider in healthcare decision-making. Monitoring, Evaluation and Documentation of Care: Utilizes case management and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures.
Case management experience required. Long term care experience preferred. Microsoft Office including Excel competent. Location: Work from Home. Candidates must reside in Miami Dade County, FL. Training will be conducted remotely via WebEx for approximately 1-2 weeks. Candidate will travel approximately 75% of the time within the region seeing Members at home, in assisted living facilities and nursing homes.
Bilingual Spanish/English Ability to multitask, prioritize and effectively adapt to a fast paced changing environment Effective communication skills, both verbal and written.
Bachelor's degree required - No Nurses. Social work degree or related field. Minimum 1 year of relevant experience in case management. Social work, Case management, Spanish.
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