Telephonic Care Manager

JOB DUTIES

• Participates in calling Medicare Advantage, (MA) members for the Telephonic Care Management Program and the COVID19 Program.
• Performs ED follow-up calls.
• Facilitates member/family/caregiver education through referrals to Complex Case Management, (CCM), Palliative Care, (PC) and Telephonic Care Management, and Hospice as appropriate.
• Identifies any psychosocial needs of the member and facilitates referrals to social work and/or behavioral health, as necessary.
• Documents relevant changes in qHMO of member’s condition or status, as they occur.
• Acts as a backup to the concurrent review RN for performing the initial hospital admission review, and collaborates with AZPC Medical Directors, for medical necessity determination for in-network hospitalized members.
• Performs re-reviews on all status changes, and collaborates with the Medical Director for appropriate status determination.
• Writes appropriate rationales on all reviews that do not meet status requested.
• Performs re-reviews on all disputed Provider Dispute Resolutions, (PDR’s) and collaborates with the Medical Director for medical necessity determinations.
• Reviews Acute Rehab and Long Term Acute Care requests for appropriate disposition with the Medical Director, and informs the hospital case manager of decision.
• Assists the Skilled Nursing Facility, (SNF RN) as needed to ensure timely and safe discharges..
• Identifies and submits to the Quality Department any potential quality issues for review as well as utilization issues; e.g., over/under utilization, delay of service issues, etc.
• Identifies and submits Potential Quality Incidents, (PQI)s to the Medical Director.
• Equally shares in after-hours, week-end rotation and Holiday coverage for Care Coordination Department.
• Strong teamwork philosophy and willingness to accept change proactively.
• Other duties as assigned.

EUCATION, TRAINING & EXPERIENCE

• Current unrestricted AZ Nursing license – BSN RN preferred.
• Knowledge of Medicare, state, and local managed care regulations, prior experience in Managed Care setting preferred.
• 3.5 years acute care or care management experience. Medical, ER, Tele, ICU or other relevant clinical role requiring quick critical thinking experience preferred.
• Must have the ability to present clinical information both accurately and confidently.
• Able to communicate effectively and in a professional manner with all levels of internal staff and external customers.
• Ability to be detail-oriented, able to function under pressure and able to prioritize and re-prioritize tasks as needed.
• Ability to work both independently and as part of a team, with minimal supervision.
• Excellent customer service and communication skills, both oral and written.
• Ability to navigate numerous Electronic Health Records systems.