Care Manager I - TRICARE North

Health Net, Inc. (NYSE: HNT) is among the nation’s largest publicly traded managed health care companies. Health Net’s mission is to help people be healthy, secure and comfortable. The company’s POS, HMO, insured PPO, behavioral health and government contracts subsidiaries provide health benefits to more than 7 million individuals. For more information on Health Net, Inc., please visit the company’s Web site at www.healthnet.com

 

JOB SUMMARY:

 

The Care Manager I is responsible for providing care management services to beneficiaries with planned admissions to acute care hospitals, or to those transitioning from case management or disease management programs. Systematically identifies and addresses fragmented care for patients with acute, real-time needs and tailors interventions and services to fill gaps and produce optimal clinical outcomes cost-effectively.

 

ESSENTIAL DUTIES AND RESPONSIBILITIES:Pre-Admission Counseling
Contacts patients with upcoming hospital admissions and discusses expectationsAssesses patient’s condition to understand illness or injury and evaluate ability to follow treatment planAdvises patients of probable length of stay and helps anticipate and arrange for services at dischargeWorks with physicians and hospitals to enforce treatment plans and ordersEnsures patient receives specialty care and tests as orderedContacts medical team members to discuss patient’s course of progress and needsArranges for and coordinates health care team services, avoiding duplication and conserving benefit dollarsEvaluates need for and authorizes equipment, supplies, servicesIdentifies problems and acts to anticipate and avoid complicationsInstructs patient and family in proper care and refers patient back to physician or other health care team members as neededIdentifies plateaus, improvements, regressions and depressions, and counsels accordinglyConfers with physician to clarify diagnosis, prognosis, therapies, daily living activities, and to share informationAuthorizes recommended modalities of treatment. Investigates and suggests alternatives appropriatelyDocuments case summary in Transitional Care Plan and shares appropriately with beneficiaries and providersFacilitates beneficiary transfers among regions and collaborates with military liaison to minimize disruption care or servicesCoordinates basic benefit. Identifies and submits modifications, requests for exceptions or special programs as warrantedAssesses patient’s benefit plan coverage and limitationsNegotiates cost-effective rates for provider services by contacting multiple providers and comparing specialty item costs, researching and identifying required equipment, and pursuing contracts accordinglySuggests medically appropriate alternatives that accomplish treatment plan goals more cost effectivelyContacts patients within 48 hours of discharge to ensure sufficient support for full recoveryEnsures proper receipt of equipment, home health and other servicesAssesses compliance with medications and follow-up appointmentsAssists patient in coordinating transportation and other basic needs, and in navigating the health care system effectively.



REQUIREMENTS:

 

Education:
Graduate of Nursing program, BSN Degree preferred, or Graduate in Clinical Psychology or Clinical Social Work

 

Certification/License:Registered Nurse, Clinical Psychologist, or Licensed Clinical Social Worker license State Drivers License

Experience:Two years clinical experience in a health care environment; including Care Coordination, Nurse Advice/Triage, Case or Disease ManagementPrevious managed care experience desired.

Knowledge, Skills & Abilities:Exceptional written and oral communication skillsDemonstrated ability to assess, evaluate and interpret medical informationSkilled in computer operation including proficiency in Microsoft Office Word,Excellent Interpersonal skills, and the ability to work effectively and independentlyHigh level of understanding of community resources, treatment options, home health availability, funding options and special programs

OR
Any combination of academic education, professional training or work experience, which demonstrates the ability to perform the duties of the position.

 

As a government contractor, this position requires U. S. citizenship and proof of favorable adjudication following submission of Department of Defense form SF85P or higher security.

 

Health Net, Inc. supports a drug-free work environment and requires pre-employment background and drug screening.

 

Health Net and its subsidiaries are an Equal opportunity/Affirmative Action Employer M/F/V/D.