Case Management Coordinator (Social Worker)

About the role

The Case Management Coordinator role focuses on improving care coordination and reducing fragmentation among clients, aiming to enhance safety, well-being, and quality of life. Care managers collaborate with clients, families, and healthcare providers to implement and monitor care plans, ensuring medical necessity and adherence to benefits.

Responsibilities

• Provides active care management, assesses service needs, and develops and coordinates action plans.
• Evaluates outcomes of plans, eligibility, level of benefits, place of service, length of stay, and medical necessity regarding requested services.
• Monitors services and implements plans, including member goals.
• Telephonic support for members with chronic conditions, high-risk pregnancies, or other at-risk conditions.
• Participates in direct intervention/patient education with members and providers regarding health care delivery systems, utilization on networks, and benefit plans.
• Serves as a member advocate through continued communication and education.
• Promotes enrollment in care management programs and/or health and disease management programs.
• Communicates with health care providers and members regarding requested services.
• Performs medical or behavioral review/authorization process, ensuring coverage for appropriate services within benefit and medical necessity guidelines.
• Makes referrals to appropriate staff for further support.
• Collects and inputs clinical information into the system for proper claims adjudication.
• Demonstrates compliance with applicable legislation and guidelines.
• Maintains current knowledge of contracts and network status of all service providers.
• Assists with claims information, discussion, and/or resolution, referring to appropriate internal support areas for proper processing.

Requirements

• Associates in a job-related field or equivalent degree.
• 4 years recent clinical experience in defined specialties such as oncology, cardiology, neonatology, maternity, rehabilitation services, mental health/chemical dependency, orthopedics, general medicine/surgery, or 4 years of utilization review/case management/clinical experience.
• Knowledge of quality improvement processes and demonstrated ability to perform these activities.
• Working knowledge of word processing software.
• Knowledge of contract language and application.
• Ability to work independently, prioritize effectively, and make sound decisions.
• Good judgment skills.
• Demonstrated customer service, organizational, and presentation skills.
• Demonstrated proficiency in spelling, punctuation, and grammar skills.
• Demonstrated oral and written communication skills.
• Ability to persuade, negotiate, or influence others.
• Analytical or critical thinking skills.
• Ability to handle confidential or sensitive information with discretion.

Skills and Abilities

• Working knowledge of spreadsheet, database software.
• Thorough knowledge/understanding of claims/coding analysis, requirements, and processes.

Preferred Work Experience

• 7 years of healthcare program management.

Preferred Education

• Bachelor's degree in Nursing.

Preferred Skills and Abilities

• Working knowledge of spreadsheet, database software.

Preferred Licenses and Certificates

• Case Manager certification, clinical certification in specialty area.

Benefits

• Subsidized health plans, dental and vision coverage.
• 401k retirement savings plan with company match.
• Life Insurance.
• Paid Time Off (PTO).
• On-site cafeterias and fitness centers in major locations.
• National discounts to movies, theaters, zoos, theme parks and more.