The Dean Health Plan Disease Case Manager is responsible for managing members in a telephonic disease/case management program who have been identified as having chronic and/or complex disease states.  This position provides assessment of the appropriate disease state and assesses the health care and educational needs of the members.  The Disease Case Manager assumes a leadership role within the interdisciplinary team to achieve optimal clinical and resource outcomes.  The Disease Case Manager is responsible for assessing, planning, implementing, coordinating, monitoring and evaluating care plans, services and outcomes to maximize the health of members.

Job Responsibilities

• Responsible for managing members in a telephonic disease/case management program.
• Conducts individualized clinical assessments.
• Screens members to identify needed medical services, modifiable risk factors and educational needs and identifies or refers cases for other services.
• Completes a comprehensive assessment and develops a care plan utilizing clinical expertise to evaluate the members need for alternative services.  Assesses short-term and long-term needs and establishes disease/case management objectives.
• Communicates with PCP/Providers regarding member needs.
• Collaborates with other Case Managers on cases to review care plans and make changes if necessary.
• Acts as a liaison and member advocate between the member and their family, physician and facilities/agencies.
• Interacts continuously with member, family, physician(s), and other providers utilizing clinical knowledge and expertise to determine medical history and current status. 
• Applies clinical criteria and guidelines to ensure appropriate administration of benefits and optimum medical outcomes.
• Authorizes and coordinates required services in accordance with the benefit plan.
• Assesses options for care including use of benefits and community resources to update the care plan as needed.
• Determines medical necessity relating to incoming correspondence and internal referrals.
• Intervenes to positively effect healthcare outcomes with emphasis on member’s self-management of their disease state.
• Maintains HIPAA standards and confidentiality of protected health information.
• Ensures compliance with all state and federal regulations and guidelines in day-to-day activities.

Job Requirements

Education/Expertise

• Registered Nurse required, Bachelor’s Degree in Nursing preferred.
• Two to four years clinical acute experience in varied health care settings with an expertise in diabetes, asthma/respiratory, and OB.
• At least one to three years of Case Management/Disease Management experience preferred.

Professional Licenses/Certifications

• Current state Registered Licensed Nurse (RN).
• Current case management certification or other applicable certifications or willingness to obtain certification after two years of employment. 

Required Skills

• Ability to work independently, handle multiple assignments and prioritize workload.
• Ability to exercise independent and sound judgment in decision making, utilizing all relevant information.
• Demonstrates high level time management, organizational skills and priority setting.
• Communicates effectively in person and by phone.
• Advanced ability as a licensed professional to communicate on any level required to meet the demands of the position.
• Ability to create, review and interpret treatment plans.
• Demonstrates negotiation skills.
• Demonstrates effective communication methods and skills, using lines of authority appropriately.
• Complies with CMSA Standards of Case Management Practice and Code of Professional Conduct.
• Valid driver’s license and personal reliable vehicle required for work-related travel.

Computer Skills