Coordinates, monitors and ensures that appropriate and timely primary, acute and long-term care services are provided to members across the continuum of care.
Assists in coordinating services with federal and state programs, and other community services to the member
Promotes effective healthcare utilization, monitors health care resources and assumes a leadership role within the Interdisciplinary Care Team (ICT) to achieve optimal clinical and resource outcomes.
Works with the Manager of Service Coordination to assess, plan, implement, coordinate, monitor, and evaluate services and outcomes to maximize the health of the Member.
Receives and reviews authorizations for services from providers and members via phone, fax or written request.
Provides clinical guidance, expertise and training to Service Coordinators who do not have the Social Work background/licensure.
Conducts face-to-face Health and Functional Assessments (HFA) for all members on an annual or more frequent basis (as applicable).
Develops a Care Plan for each member, in conjunction with the PCP and member, based upon the HFA.
Interacts with member, family, physician(s), and other providers utilizing clinical knowledge and expertise to determine medical history and current status and to assess the options for care including use of benefits and community resources to update the Care Plan.
Coordinates community resources with emphasis on the development of natural support system and coordinates benefits, regulations, laws and public entitlement programs.
Maintains HIPAA standards and confidentiality of protected health information; and reports critical incidents and information regarding quality of care issues.
Utilizes compiled data received from member electronic record to assure that the services being provided meet the memberâ€™s needs.
Facilitates member and provider authorization and access to services.
Seeks to resolve any concerns about care delivery or providers.
Monitors member self-direction delivery process.
Assists QI department with monitoring of progress with Early and Periodic Screening, Diagnosis and Treatment (EPSDT) requirements.
Refers members with suspected severe emotional, behavioral and/or mental illness for evaluation.
Manages a caseload that does not exceed 1880 hours annually, based on case intensity and acuity.
Acts as liaison and member advocate between the member/family, physician and facilities/agencies.
Maintains accurate records of service coordination activities in the system using clinical guidelines.
Ensures compliance with all state and federal regulations and guidelines and within WC guidelines in day to day activity.
Provides counseling on options regarding institutional placement and HCBS alternatives.
Assists members in transitioning to and from nursing facilities/residential facilities.
Other duties as assigned.
Education and Experience: Required A Master's Degree in (M.S. or M.A) in clinical social work, psychology, counseling, rehabilitation or other relevant field. Required 2+ years of experience in health care with client care coordination responsibilities (preferably in long-term care). Required Other Experience working as a Case Manager . Required Other Experience in working with special populations, such as HIV/AIDS, developmental disabilities, medically fragile children, geriatrics, persons with neurotrauma, and younger adults with physical disabilities. Preferred Other Managed care experience
Since its founding as a single local healthcare plan in 1984, Centene's heart and soul has been linked to the health of the communities we serve. From that day until now, Centene has worked tirelessly to fulfill needs in healthcare and help more individuals.
As we go about our work today, this long-held commitment to the lives of children, families, seniors, people with disabilities and many more is encapsulated in our purpose: Transforming the health of the community, one person at a time.