Transition of care, Case Manager - Altamed Health Services - Remote
(2023-09)
- Responsible for reviewing the daily discharge list from acute care facilities and determining medical acuity
- Reviews all inpatient records of eligible TOC members and creates a synopsis of inpatient stay. This will include documentation of newly started medications and completed studies within the designated EMR.
- Responsible for the daily review and processing of referral authorizations for members, followed by the Transitions of Care Team
- Assists with coordinating any post-discharge needs, as determined by TOC provider teams.
- Creates inpatient charts on EPIC for non-FQHC members.
- Participates in quarterly in-person training sessions.
- Transmits appropriate clinical information to physician offices via email and E-fax.
- Manages patients throughout the continuum of care.
- Attends Joint Operation Committee (JOC) meetings and various community meetings as needed.
- Performs other duties as assigned.
Prior Authorization/UM Review Nurse - Optum Monarch - Temporary Remote
(2023-08 - 2024-03)
- Assesses services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines.
- Prepares prior authorization documentation for review by UM Manager
- Make clinical decisions based on clinical guidelines and established criteria
- Analyzes clinical service requests from members or providers against evidence based clinical guidelines.
- Identifies appropriate benefits and eligibility for requested treatments and/or procedures.
- Conducts prior authorization reviews to determine financial responsibility for Molina Healthcare and its members.
- Processes requests within required timelines.
- Refers appropriate prior authorization requests to Medical Directors.
- Requests additional information from members or providers in consistent and efficient manner.
- Makes appropriate referrals to other clinical programs.
- Collaborates with multidisciplinary teams to promote Molina Care Model
- Adheres to UM policies and procedures.
TOC Case Manager - Imperial Health - Remote
(2022-02 - 2023-08)
- Provide telephonic contact within 2 business day of all Medicare Advantage patients discharged from all inpatient facilities (hospital, SNF, LTAC. IRF) and after ED visits for patients that are considered at increased risk for readmission
- Conduct Transition of Care assessments that include the medical, behavioral, pharmaceutical, and social needs of the patient, identify gaps in care and barriers to good health
- Create and implement a care plan that will address identified needs, remove barriers to care, and improve the health of the patient
- Coordinate care by serving as the advocate and resource for the patient, their family, and their provider(s)
- Facilitate care across the continuum of care, spanning settings such as the home, hospital, skilled nursing facility, and acute care facility
- Manage patients during periods of transitions of care to facilitate effective transitions and minimize avoidable readmissions
- Assess the patient's knowledge of their discharge care requirements and renal condition and provide education and self-management support
- Provide ongoing reassessment and follow-up to improve patient outcomes
- Provide clinical oversight to non-licensed support team of community health workers and health coaches and licensed support team of social workers and renal dieticians, and delegate tasks as appropriate
- Track and trend the information, along with the data provided by the health plan, identifying those diagnoses, co-morbidities and other factors that impact readmissions
- Perform telephonic assessment of patient status, treatment plan adherence, physician follow-up, need for intervention including medication reconciliation and document all relevant information in EHR
Enhanced Case Manager - Health Care Support (Conifer Health) - Remote
(2022-07 - 2022-12)
- Screening and reviewing prospective, concurrent, and retrospective referrals and authorizations for medical necessity and appropriateness of service and care and discussing with Medical Directors
- Coordinate health care services with appropriate physicians, facilities, contracted providers, ancillary providers, allied health professionals, funding sources and community resources
- Prospective review to determine appropriateness of denial, possible alternative treatment, and draft denial language to ensure consistent application of standardized, nationally recognized UM criteria and appropriate use of denial language
- Coordinate out -of- network and out - of - area cases with member, health plans and Case Management team
- Review's patient referrals within the specified care management policy timeframe (Type and Timeline Policy)
- Develop and maintain effective working relationships, with physicians and office staff
- Demonstrates a thorough understanding of the cost consequences resulting from care management decisions through utilization of appropriate reports such as Health Plan Eligibility and Benefits and Division of Responsibility (DOR)
- Maintains effective communication with the health plans, physicians, hospitals, extended care facilities, patients, and families
Outpatient Case Manager - WelbeHealth - Hybrid
(2021-03 - 2022-07)
- Keeps member/family members or other customers informed and requests if necessary, further assistance when needed.
- Demonstrates the ability to follow through with requests, sharing of critical information, and getting back to individuals in a timely manner.
- Functions as liaison between administration, members, physicians and other healthcare providers.
- Interacts professionally with member/family/physicians and involves member/family/physicians in formation of the plan of care.
- Performs a Clinical Assessment/Questionnaire of the member and determines an acuity score for necessary scheduled follow-up.
- Develops an outcome-based plan of care, based on the member's input and assessed member needs. Implements and evaluates the plan of care as often as needed as evidenced by documentation in the member's case file.
- Educates the member/caregiver on the transition process and how to reduce unplanned transitions of care.
- Manages transition of care from the sending to receiving settings ensuring that the Plan of Care moves with the member and updates/modifies the care plan as the member's health care status changes
- Communicates appropriately and clearly with physicians, in patient case managers and Prior-Authorization nurses
- Identifies community resources to address needs not covered by the member's benefit plan, and coordinates member benefits as needed, with the health plan.
- Participates in the efficient, effective and responsible use of resources such as medical supplies and equipment.
- Responsible for the coordination and facilitation of member and family conferences as determined by assessment of member's needs.
- Identifies the appropriate members to participate in the interdisciplinary case round process. Prepares the necessary summary information to present to the team.
- Responsible for the coordination of clinic appointments, medication reconciliation, PCP and SPC visits.
- Ability to collaborate and communicate with all members of the healthcare team (concurrent review, pre-authorization, PCP/SPC, Social Services, and Pharmacy) to coordinate the continuum of care of developing plans for management of each case.
Ambulatory Case Manager - Independent Living Systems - Remote
(2016-02 - 2021-03)
- Conduct Face to Face Health Risk Assessments (HRA), to identify Kaiser Permanente member's LTSS needs in a timely, engaging and professional manner
- Develop Care Plans and interventions within the care manager scope of practice, including workflows, P&Ps and timelines
- Supervise and coordinate with care assistants to schedule initial assessment for direct referrals and expedited members.
- Refer non-LTSS needs to KP Case Manager
- Refer member to appropriate LTSS resources: CBAS, IHSS, MSSP, community resources, and waiver programs. Facilitate access to LTSS resources as needed.
- Provide service coordination in an effective and timely manner.
- Document all services in eCare utilizing the D.A.P. format.
- Collaborate with KP CMs, providers, social workers, etc. in response to member needs.
- Respond to direct referrals within prescribed timelines.
- Engage family and other care givers – building and strengthening relationships
- Respond appropriately (as specified in workflows and policies and procedures) to: DME needs, Safety issues, Emergency situations, and suspected abuse/neglect
- Engage in effective transition of care from inpatient/SNF setting to home or different levels of care.
- Ensure proper continuity of care when cases are transferred between CMs.
- Maintain effective and timely communication with care assistants and other care team members
- Develop and make case presentations
- Foster relationships with KPCMs, community resource sources, and CBAS, MSSP, IHSS, Waiver program representatives
- Attend meetings, training sessions and conferences
- Complete Administrative tasks – read/respond to emails, track mileage, maintain ADP, etc.
- Properly utilize technology and electronic systems
- Effectively manage caseload
Hospice Nurse - Royal Hospice
(2019-04 - 2020-07)
- Collaborate with physicians and other professionals to plan care
- Make frequent visits to the patient to evaluate
