Case/Care Manager II

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: 


Provides Case Management services to a specific clientele. Screens cases for possible case management services according to predetermined criteria.  Authorizes inpatient and/or outpatient treatment according to company's stated criteria.  Evaluate physician's treatment plan and other records to develop a care plan to assist patient to move as rapidly and cost effectively as possible through health care services.  Consults with providers, beneficiaries and family members as needed.  Documents all initial and concurrent reviews, including, but not limited to diagnosis, symptoms, interventions, goals and plan for next review.  Identifies providers for specialized services and negotiate rates when services are provided outside the contracted provider network.  Supervises and monitors the duties and responsibilities assigned to the Case Management Assistant.

 

ESSENTIAL DUTIES AND RESPONSIBILITIES:Contacts patient to assess the patient’s condition, understanding of his/her injury and the patient’s ability to follow the treatment plan. Contacts members of the medical team to discuss the patient’s course of progress and needs utilizing available discharge information (if there was a hospitalization) and the initial needs assessment. Arranges for all services required coordinating services with the health care team to eliminate duplication of service and conserve health benefit dollars. Contacts or visits family to ascertain its understanding of the patient’s diagnosis and prognosis and it ability to provide caregiver support. Checks home for safety factors and architectural barriers and arrange for any modifications. Identifies problems, anticipates complications and acts to avoid them, providing health instruction to the patient and family and referring the patient back to the physician or other health care team members when appropriate. Identifies plateaus, improvements, regressions and depressions; counseling accordingly and recommending help. Makes personal visits or contacts the physician to clarify diagnosis, prognosis, therapies, activities of daily living, etc. Provides authorizations for any modalities of treatment recommended; investigation and suggesting alternative treatments when appropriate. Assists with obtaining information and forms regarding living wills, health care proxy, do-not-resuscitate order, etc. Documents case summary based on information received and communicates with the beneficiaries and involved providers. Conducts personal visits to the patient’s home or hospital. Facilitates transfers of beneficiaries throughout the different regions and within the region by collaborating with the military liaison to transition the beneficiary with minimal disruption of their health care services. Coordinates the basic benefit and identifies and submits benefit modifications as appropriate or submits a request to TMA for benefit exceptions or special programs Educates physicians and appropriate MTF personnel regarding benefits and limitations as well as payment processes. Collaborates with the physicians, beneficiaries/families, and involved providers to evaluate the beneficiary needs and ensure beneficiaries are receiving adequate services to meet their needs. Conduct training for other HNFS associates regarding the overall Case Management Program and specific processes such as the case management referral process.




REQUIREMENTS:



At least one (1) of the following:


A bachelors (or higher) degree in a health-related field and licensure as a health professional (where such licensure is available).

Certification as a Case Manager.

RN licensure and three (3) years clinical practice experience and practice case management within the scope of their licensure (based on the standards of the discipline).


Education:


Graduate of Nursing program, BSN Degree preferred.



Certification/License:


Valid Registered Nurse, Clinical Psychologist, or Licensed Clinical Social Worker license, Valid State Drivers License, and Certified in Case Management (CCM) recommended.



Experience:

5 years clinical experience in a health care environment.
2 years proven case management experience required.
TRICARE or managed care experience desirable.


Knowledge, Skills & Abilities:

Demonstrated ability for assessment, evaluation and interpretation of medical information.
Skilled in the operation of the computer including proficiency in Microsoft Office Word, Excel and Access.
Should have a high 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.