Position Scope:

• Manages/coordinates an active caseload of case management cases for Cigna Heath Care or CareAllies Case Management.
• Uses clinical knowledge to assess the treatment plan and goals, and identifies gaps in care or risks for readmission or complications.
• Establishes patient centric goals and interventions to meet the member’s needs
• Interfaces with the member, family members/caregivers, and the healthcare team, and embedded care coordinator as well as internal matrix partners.
• Balances business needs with patient advocacy
• Build solid working relationships with internal staff, matrix partners, key functional areas, customers, and providers

Summary description of position:

This position, the Case Manager Specialist, through the case management process, will promote the improvement of health outcomes to members and assist those members experiencing the burdens of illness and injury. The Case Manager will assess, plan, implement, coordinate, monitor and evaluate options and services to meet an individual’s health needs within case load assignments of a defined population based on business perspectives. The Case Manager will promote quality cost-effective outcomes managing care needs through the continuum of care utilizing effective verbal and written communication skills and a consumerism approach through education and health advocacy to members serviced.  Ability to work independently and effectively communicate to internal and external customers in a telephonic environment.  The CAC aligned Case Manager has enhanced collaboration with Physician Group Embedded Care Coordinators (ECC).

Major responsibilities and desired results:

¨Obtains informed verbal consent and takes all steps to obtain written consent as appropriate.

• Establishes a collaborative relationship with client (plan participant/member), family, physician(s), and other providers to determine medical history and current status and to assess the options for optimal outcomes.
• Promote consumerism through education and health advocacy.
• Assesses member’s health status and treatment plan and identifies any gaps or barriers to healthcare. Establishes a documented patient centric case management plan involving all appropriate parties (client, physician, providers, employers, etc), identifies anticipated case results/outcomes, criteria for case closure, and promotes communication within all parties involved.
• Implements, coordinates, monitor and evaluate the case management plan on an ongoing, appropriate basis.
• Negotiates price, level of care, intensity and duration with provider(s), as appropriate.
• Acts as a timely and proactive liaison between account, client/family, physician(s) and facilities/agencies
• Maintains accurate record (system) of case management interventions including cost/benefit analysis, savings, and data collection.
• Adheres to professional practice within scope of licensure and certification quality assurance standards and all case management policy and procedures
• Compliant with all accreditation, State and Federal mandates
• Delivers utilization review services when member is in active case management as appropriate
• Participates in unit and corporate training initiatives and demonstrates evidence of continuing education to maintain clinical expertise and certification as appropriate.
• Demonstrates sensitivity to culturally diverse situations, clients and customers.
• Based on experience, may provide leadership, preceptor/mentorship, support and coverage to other case management staff and assist case managers in achieving positive outcomes and savings
• Engage our CAC partner (Embedded Care Coordinator) to support service to our customers.

• Participates in committees, task forces and other company projects as assigned and other assigned tasks as deemed necessary to meet business needs.
• Other duties as required and related to this role

Minimum requirements:

Active unrestricted Registered Nurse (RN) license in state or territory of the United States Two years full-time equivalent of direct clinical care to the consumer

Preferred requirements:

• Clinical experience in acute care, or a clinical setting, or case management including experience/expertise in one of the following selected fields of nursing:  Intensive Care / Obstetrics/ Cancer Care / Rehabilitation / Coronary Care / Neurology / Trauma / Neonatology / Respiratory Care / Transplant Dialysis / Medical-Surgical/ Home Health / Hospice/Pediatrics
• Within four (4) years of hire as a case manager, the case manager will possess a URAC-recognized certification in case management.

Competencies preferred :

• Excellent time management, organizational, research, analytical, negotiation, communication (oral and written) and interpersonal skills
• Strong personal computer skills, MS word, Excel, Outlook experience, and Internet research desired
• Knowledge of the insurance industry and claims processing
• Service marketing/sales and business acumen experience a plus
• Strong skills in the following areas:  teamwork, conflict management, assessment complex issues, ability to recommend changes and resolve problems through effective decision making
• Experience in medical management and case management in a managed care setting is highly desirable
• Knowledge of managed care products and strategies
• Demonstrated sensitivity to culturally diverse situations, participants and customers
• Ability to work within changing business environment and balance business needs with patient advocacy
• Experience managing multiple projects in a fast paced matrix driven environment
• Demonstrated ability to coach and educate other case management staff
• Demonstrate effective organizational skills and flexibility to meet the business needs