Medical Case Manager - Awesome Practice Environment

Action Healthcare Management Services, Inc. (AHM) is an independent, woman owned, medical management company, based in Phoenix, AZ. Founded in 1987, our primary focus is providing comprehensive integrated healthcare management, including Utilization Management, Case Management, Disease Management, High Risk Pregnancy management, Predictive Management, to self-funded employer groups and Taft-Hartley Trusts, throughout the United States. At AHM, we pride ourselves on our knowledgeable and experienced staff dedicated to delivering exceptional patient and client-centered service. Our AHM team enjoys their jobs and makes a positive difference in the quality of the health and well being of our patients. 

 

Job Summary

 

The AHM Case Manager is responsible for assessing the health care needs of covered members, identifying options and coordinating the appropriate care and services, and serving as a patient advocate. Medical management services are provided telephonically and include a comprehensive health and life style assessment, case management goal planning and implementation, coordination of resources, and monitoring and measuring of patient outcomes. We use best practice and established case management and clinical guidelines to guide the management of all cases. The average caseload is 35-40 patients per Case Manager. Case Managers serve on the Utilization Management and Quality Management Committees and are responsible for assisting with the Quality Management processes and Predictive Management.

 Key Responsibilities and Functions

 

1.  Conduct a thorough and objective evaluation of the member?s need for case management services

2.  Evaluate financial and other resources available to the member

3.  Assess resource utilization and cost management for present and future treatment

4.  Seek authorization for case management from the member or responsible party and from the client as necessary

5.  Negotiate fees as appropriate for exceptions to benefits and out-of-network service

6.  Maintain effective communication and collaboration with the member, family members, physicians, other healthcare team members, and AHM client representatives

7.  Compare the member?s disease course and treatment plan to established clinical guidelines to determine variances and opportunities to intervene

8.  Routinely assess the member?s progress, status, and outcomes

9.  Establish measurable goals that promote effective cost and quality of life outcomes

10.Accurately document and report all case management activities and  outcomes

11.Maintain cost-benefit analysis documentation and reports as  required

12.Coordinate review and approval of services with the AHM UM staff

13.Maintain confidentiality of patient information

14.Document all billable time spent on all billable cases, according to AHM policy

 

Required Knowledge and Experience

 

The Case Manager will have an understanding of and experience providing the principle standards of case management:

 Coordination and Service Delivery - The Case Manager will understand confidentiality and the legal and ethical issues pertaining to case management, be able to obtain an accurate history, establish care management goals, and establish working relationships with all customers.Community Resources ? The Case Manager will understand the importance of utilizing, and the process for accessing, community resources to provide cost effective supportUtilization Management ? The Case Manager will have a knowledge of Utilization Management principles and practices, managed care processes, and an understanding of the various insurance and coverage modelsPreferably 3 years of case management and managed care experienceMinimum of 5 years medical-surgical clinical experience

 Qualifications

 Arizona licensed Registered Nurse - unrestrictedA BSN and/or a graduate degree in a related field is recommended The Case Manager must maintain continuing competence appropriate to case management. CCM certification is preferred Ability to work independently as well as provide creative ideas and support to the health care teamMust have excellent interpersonal, verbal and written communication skillsStrong computer skills including ability to type with competence, use of Microsoft office applications, including spreadsheet application