Sr Case Specialist
Summary:
JOB SUMMARY:
Responsible for managing care and services to members. Case Specialists works in conjunction with Case Managers to coordinate health care services by facilitating, scheduling, and arranging a variety of treatment and health care plans.
Responsibilities:
PRIMARY RESPONSIBILITIES:
1. Coordinates daily activities of the clinical support unit, including coordination, authorization, monitoring and tracking of health care services.
2. Has responsibility for the interface between Healthcare Management Services and Case Specialists.
3. Monitors telephone queue to ensure adequate coverage.
4. Acts as a resource for staff on decision making and problem solving in accordance with AMERIGROUPs Policy and Procedures and approved criteria. Assumes problem solving role in repetitive problems.
5. Monitors ongoing communication with service providers.
6. Evaluates current processes of all clinical support functions.
7. Determines and recommends changes for increased efficiencies and improved outcomes.
8. Determines training needs. Assists in development of training materials. Ensures adequate training for new and current staff and ongoing education support staff.
9. Participates in internal/external audits, as requested.
10. Participates in internal/external departmental activities/assignments.
11. Maintains member confidentiality.
12. Creates a positive work environment among team members. 13. Participates in Quality Improvement Process.
14. Coordination, authorization, fulfillment, monitoring and tracking of health care services.
15. Establish working relationships with referral sources
16. Initiates and maintains contact with assigned individuals/significant others and providers to determine members response to services.
17. May coordinate home visits for Case Managers and coordinate assignments for Case Managers to facilitate timely member evaluation.
18. Review of benefit systems.
19. Identifies cases in consultation with Case Manager that would benefit from alternative care.
20. Arranges for services as identified by the case manager such as home health resources, alternative long-term care placements etc.
21. May be responsible for individual services over a large service area or state-wide.
22. Knowledge of care-coordination and case management concepts.
23. Identifies potential liability issues for services provided.
24. Utilizes knowledge of community resources.
25. Refers members to case management as indicated.
26. Ensures that health care services are received as authorized by the provider.
27. Collaboratively works with other departments.
28. Utilizes excellent customer service principles to assist internal and external customers.
29. Maintains member confidentiality.
30. Other duties as requested or assigned.
Qualifications:
JOB REQUIREMENTS:
Education Required:
- Associate Degree required (or equivalent experience)
- High School diploma or GED required
Preferred:
- Bachelors degree preferred
- Medical Terminology preferred
Years and Type of Experience Required:
Required:
- Min of (4) years working in Health Services field(2 of the 4 within the AMGP HCMS dept)
- Bilingual an asset.
- Knowledge of care-coordination and case management concepts.
- Proven AMERIGROUP experience, with demonstrated record of minimum two years working in the Healthcare Management Services department
- Supervisory Experience Preferred
Other Required:
- Computer literate
- Excellent verbal and written communication skills.
- Strong decision making skills.
- Ability to provide services in an environment that involves multiple health care systems.
- Ability to interact with all relevant components of the health care system.
- Ability to provide services that deal with the individuals broad spectrum of needs
- High energy level.
- Self-starter with ability to handle multiple projects at one time. - Appreciation of cultural diversity and sensitivity towards target population.
Preferred: Bilingual a plus.
PHYSICAL REQUIREMENTS:
- Must be able to operate a computer.
- Must be able to operate a telephone
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