1.0 FTE Full time Day – 08 Hour R2334067 Remote 86242 PI-POPULATION HEALTH-HPO Nursing 180 El Camino Real,PALO ALTO,California
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Day – 08 Hour (United States of America)
This is a Stanford Health Care job.
A Brief Overview
The Care Managers are responsible for the risk stratification of at-risk patient populations, acute and skilled nursing facility concurrent review and complex and episodic case management, including the care plan development and ongoing intervention strategies. This position acts as a resource, providing feedback on appropriate complex case management referrals and working collaboratively with all disciplines to manage the complex patients. Key member of the Stanford Health Plan Clinical Operations team, supporting Stanford Health Care Alliance and Stanford Healthcare Advantage health plans, and facilitates seamless, coordinated care and safe and timely transitions in care for high risk members. S/he works closely with members, caregivers, providers, facility staff, and health plan representatives to conduct member assessments, coordinate care, proactively identify and address barriers to effective transitions in care, and provide complex case management, telephonically and in person in member homes, provider offices or facility settings. S/he will conduct concurrent review and issue appropriate member/provider correspondence.
Stanford Health Care
What you will do
- Inpatient & SNF Utilization Management & Care Coordination:
- Support proactive hospital discharge planning, transfers, and redirections through collaborative care planning.
- Develop individualized care plans for all complex case management patients, including regular updates with distribution throughout the care team.
- Proactively and collaboratively interface with HMOs, physicians, internal staff and family members to assist in developing a well-rounded care plan.
- Complete health risk assessments for selected senior patients as needed.
- Serves as a liaison between hospital, health plan, providers, caregivers, family, and the patient.
- Identify opportunities to improve utilization, quality of care, access issues and physician profiling.
- Acts as a resource for provider and patient education as necessary.
- Reduce avoidable inpatient and SNF bed days through telephonic & in person concurrent review, proactive assessment of barriers to discharge, and collaboration with key parties (health plan, facility, provider office, member and family) to facilitate safe and timely discharge or transition.
- Apply standard clinical criteria, document decisions and issue related member and/or provider correspondence.
- Ensure seamless and safe transition of care, through inpatient and SNF bed-side visits, post discharge coordination with members, providers and ancillary services, including related bedside visits, post-discharge calls and/or visits to members. Referral to telephonic case management, if appropriate.
- High Risk Member Complex Case Management:
- Proactively review Health Risk Assessments and at-risk patient populations for identification of patients appropriate for case management.
- Provide regular feedback to providers, inpatient case managers, and utilization management coordinators on the appropriateness of complex case management referrals.
- Develop and implement care coordination services for complex patients as needed, including scheduling appointments, home health, DME, transportation, financial assistance, and linkages with community resources.
- Identifies and refers high-risk members to delivery system chronic disease care programs to improve quality of care.
- Maintains daily electronic case management case list. Effectively uses case management software programs as designated.
- Attends weekly interdisciplinary care team meetings to discuss complex cases and integrate input from the entire team.
- Meet production standards: Adheres to all SHC Health Plan policy and procedures Manages caseload of approximately 50-150 complex and/or rising risk case management patients.
- Provide telephonic and/or onsite case management for members requiring a higher level of complex case management which may include periodic visits at the member’s home or provider settings
- Complete comprehensive assessment of clinical & non-clinical risk factors impacting member’s health status.
- Develop and coordinate implementation of individualized, member centered care plans, involving member, care givers, providers and other stakeholders to ensure alignment, including scheduling appointments, home health, DME, transportation, coordinating financial assistance, and linkages with community resources.
- Effective coordination and communication with Medical Directors and clinical staff.
- All other duties as assigned including department-specific functions and responsibilities:
- Meet departmental review and documentation standards for work assignments.
- Adhere to the policy and procedure of assigned hospital(s).
- Build and maintain appropriate relationships on behalf of SHC Health Plan.
- Attend departmental and company meetings as indicated by management. Includes developing and/or presenting reports to Board directors, health plans, medical groups and other committees.
- Performs other duties as assigned and participates in organization projects as assigned.
- Adheres to safety, P4P’s (if applicable), HIPAA and compliance policies.
- High School Diploma or GED High School Diploma or GED equivalent.
- BSN degree from accredited university.
- Minimum of 2 years case management in a managed care environment (HMO, Health Plan, IPA or Medical Group).
- Minimum of 1-year complex case management experience.
- Experience in concurrent review, discharge planning and transition management.
- Working knowledge of CMS and NCQA requirements for documentation and communication.
- 2-3 years in a senior role Preferred
Required Knowledge, Skills and Abilities
- Verbal and written communication skills demonstrate courtesy, compassion and helpfulness in a professional manner towards employees, patients and patient families.
- Advanced Windows skills to include keyboarding, mouse movement and computer data entry skills to enter patient information.
- Organizational and multi-tasking skills.
- Ability to work with others in a flexible, cooperative and collaborative manner.
- Requires concentration to handle varying procedures and interruptions.
- Working knowledge of clinical criteria set (Milliman, Inferqual, Medicare, Health Plan)
- Knowledge of medical terminology and medical coding, including but not limited to ICD-10, CPT, HCPCS, ASA
- Knowledge of medical management statistics relating to UM/CM and prior authorization process management.
- Extensive knowledge of risk stratification methods and complex case management criteria.
- Working knowledge of regulatory entities and regulations (CMS, DMHC, NCQA, etc.)
- Working knowledge of care management systems.
- Time Management: the ability to organize and manage multiple priorities
- Excellent oral and written communication skills
- Strong customer orientation
- Ability to work within a team environment as well as an individual contributor.
- Ability to solve practical problems and deal with a variety of concrete variables.
- Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.
- Maintain attention to detail when completing multiple or repetitive tasks.
- Ability to create basic business correspondence and write descriptive and factual prose.
- Ability to develop and maintain strong rapport with clients, effectively responding to questions in person and over the telephone.
- Understands client needs, identifies root causes of problems, and develops and implements creative and pragmatic solutions.
- Uses logic and various problem-solving techniques to deal with technical queries.
- Demonstrated ability to review utilization reports and data.
- Ability to identify trends and make recommendations for improvement.
Licenses and Certifications
- RN – Registered Nurse – State Licensure And/Or Compact State Licensure
- CCM – Certified Case Manager
These principles apply to ALL employees:
SHC Commitment to Providing an Exceptional Patient & Family Experience
Stanford Health Care sets a high standard for delivering value and an exceptional experience for our patients and families. Candidates for employment and existing employees must adopt and execute C-I-CARE standards for all of patients, families and towards each other. C-I-CARE is the foundation of Stanford’s patient-experience and represents a framework for patient-centered interactions. Simply put, we do what it takes to enable and empower patients and families to focus on health, healing and recovery.
You will do this by executing against our three experience pillars, from the patient and family’s perspective:
- Know Me: Anticipate my needs and status to deliver effective care
- Show Me the Way: Guide and prompt my actions to arrive at better outcomes and better health
- Coordinate for Me: Own the complexity of my care through coordination
Equal Opportunity Employer Stanford Health Care (SHC) strongly values diversity and is committed to equal opportunity and non-discrimination in all of its policies and practices, including the area of employment. Accordingly, SHC does not discriminate against any person on the basis of race, color, sex, sexual orientation or gender identity and/or expression, religion, age, national or ethnic origin, political beliefs, marital status, medical condition, genetic information, veteran status, or disability, or the perception of any of the above. People of all genders, members of all racial and ethnic groups, people with disabilities, and veterans are encouraged to apply. Qualified applicants with criminal convictions will be considered after an individualized assessment of the conviction and the job requirements.
Base Pay Scale: Generally starting at $70.43 – $93.34 per hour
The salary of the finalist selected for this role will be set based on a variety of factors, including but not limited to, internal equity, experience, education, specialty and training. This pay scale is not a promise of a particular wage.
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