Embedded Case Manager at Forbes Hospital

Company :

Highmark Inc.

Job Description : 

JOB SUMMARY

This job owns and conducts oversight over a specified panel of inpatient members that range in health status/severity and clinical need at Forbes Hospital. The incumbent assesses health management and psychosocial needs of the assigned member panel and utilizes data/analytics, in conjunction with clinical judgement and hospital care team insight, to identify the right clinical intervention for each member and support the discharge planning process. The incumbent supports multiple teams and processes from both the Provider and Health Plan. The incumbent works within facility processes to coordinate, connect, and collaborate in order to identify and address barriers, eliminate redundancies, streamline inefficiencies and improve member satisfaction and outcomes. The incumbent serves as an embedded resource to gather relevant information, assist in discharge planning options, help resolve barriers and placement issues, and refer members to appropriate resources post discharge. The incumbent conducts face to face member visits as needed for the purposes of providing real-time support for utilization and case management needs, participating in discharge planning and transitions of care, initiating plans of care and making introductions and referrals to Highmark programs and resources. The incumbent monitors, improves, and maintains quality outcomes (clinical, financial and functional) for the specified panel with the primary objective to improve member experience by strengthening enterprise utilization and case management.

ESSENTIAL RESPONSIBILITIES

• Coordinate with current processes to assure needs of the patient/member are met, care teams are aligned, hand offs are seamless.
• Organize daily workload from available data so that work is timely, efficient and comprehensive.
• Understand the clinical and psychosocial situation of the member and serve as a liaison to the Highmark Integrated Care Team and Inpatient Team in obtaining any outstanding information about the member.
• Communicate with the hospital care teams to identify, monitor and work toward timely resolution of transition of care challenges.
• Participate in daily discharge planning discussions to inform of discharge options, support the most appropriate discharge plan, help resolve barriers and placement issues, assure the right resources are in place prior to discharge and assist with post-acute transitions.
• Introduce the member to the Highmark case manager or other resources who will support post-discharge needs. Coordinate calls, maximize resources and referrals and share appropriate content.
• Screen the daily census for all lines of business and all Highmark members to identify high-cost admissions, readmissions and other high-risk members; prioritize.
• Other duties as assigned or requested.

​ EDUCATION

Required

• Completed a RN training program or Bachelor's Degree in Nursing OR
• Bachelor’s or Master’s Degree in Social Work

Substitutions

• Completion of RN training program in lieu of Bachelor's degree in Nursing

Preferred

• None

EXPERIENCE

Required

• 5 - 7 years in Clinical Services, Case Management, Disease/Condition Management, Provider Services or the Health Insurance Industry

Preferred

• None

LICENSES AND CERTIFICATIONS

Required

• Current Registered Nurse OR Social Work state licensure required. Additional specific state licensure(s) may be required depending on where clinical care is being provided.

Preferred

• None

SKILLS

• Written & Oral Presentation Skills
• Negotiation
• Organization

Position Type

Office-Based at Forbes Hospital

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times.  In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines