Pediatric RN Field Case Manager (Lakeland, FL)
- Lakeland Highlands Rd, Lakeland, FL, USA
Headquartered in Tampa, Fla., WellCare Health Plans, Inc. (NYSE: WCG) focuses primarily on providing government-sponsored managed care services to families, children, seniors and individuals with complex medical needs primarily through Medicaid, Medicare Advantage and Medicare Prescription Drug Plans, as well as individuals in the Health Insurance Marketplace. WellCare serves approximately 5.5 million members nationwide as of September 30, 2018. WellCare is a Fortune 500 company that employs nearly 12,000 associates across the country and was ranked a "World's Most Admired Company" in 2018 by Fortune magazine. For more information about WellCare, please visit the company's website at www.wellcare.com. EOE: All qualified applicants shall receive consideration for employment without regard to race, color, religion, creed, age, sex, pregnancy, veteran status, marital status, sexual orientation, gender identity or expression, national origin, ancestry, disability, genetic information, childbirth or related medical condition or other legally protected basis protected by applicable federal or state law except where a bona fide occupational qualification applies. Comprehensive Health Management, Inc. is an equal opportunity employer, M/F/D/V/SO.
Works with Care Coordination MVP Team members to assess, plan, implement, coordinate, monitor, and evaluate services and outcomes to maximize the health of the Member. Coordinates, monitors and ensures that appropriate and timely primary, acute and long-term care services are provided to members across the continuum of care. 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 for member. Coordinates the care and services of selected member populations across the continuum of illness. Promotes effective utilization and monitors health care resources. Assumes a leadership role within the interdisciplinary team to achieve optimal clinical and resource outcomes. Works directly with the member in the field, i.e., inpatient bedside, member's home, provider's office, hospitals, etc. while collaborating with management to assess, plan, implement, coordinate, monitor and evaluate services and outcomes to maximize the health of the member.
REPORTS TO: Supervisor, Field Care Management, PHS-FL CMS
POSITION LOCATION: Winter Haven, or Lakeland, or Bartow, or Sebring, or Avon Park, Florida
- Evaluates members for case management services and determines appropriate level of care coordination/ management services for member.
- Completes a comprehensive assessment and develops a care plan utilizing clinical expertise to evaluate the members need for alternative services.
- Acts as a primary case manager for members identified as Complex as defined by Case Management Program Description.
- Develops and monitors members plan of care, to include progress toward meeting established goals and self-management activities.
- Interacts continuously with member, family, physician(s), and other providers utilizing clinical knowledge and expertise to determine medical history and current status. Assess the options for care including use of benefits and community resources to update the care plan.
- Supervises and/or acts as a resource for non-clinical staff (i.e., Service Coordinators and Field Social Workers).
- Act as liaison and member advocate between the member/family, physician and facilities/agencies.
- Maintains accurate records of case management activities in the Enterprise Medical Management Automation (EMMA) System using clinical guidelines.
- Coordinates community resources, with emphasis on medical, behavioral, and social services. Applies case management standards, maintains HIPAA standards and confidentiality of protected health information and reports critical incidents and information regarding quality of care issues.
- Ensures compliance with all state and federal regulations as well as Corporate guidelines in day-to-day activities.
- Meets with clients in their homes, work-sites, physician’s or hospital to provide management of services.
- Adapts to changes in policies, procedures, new techniques and additional responsibilities.
- Participates with other Case Managers and Medical Directors in regular or special meetings such as Clinical rounds.
- Perform other duties as assigned.
- Travel to inpatient bedside, member’s home, provider’s office, hospitals, etc required with dependable car. May spend up to 70% of time traveling with exposure to inclement weather and normal road hazards. May require climbing multiple flights of stairs to a member's home, provider's office, etc.
- Required A Bachelor's Degree in Health Services or Nursing
- Required or equivalent work experience
- Required 2 years of experience in clinical acute care, post acute care, home health care, or maternity
- Preferred 1 year of experience in current case management
- Preferred Other Managed care experience
- Preferred Other Prior utilization management experience preferred in some geographic regions
- Preferred Other Experience in care of the elderly is required in some geographic regions
- Preferred Other Experience in home health, physicians office or public health
- Required Other Associates supporting Florida's Children’s Medical Services (CMS) must have a minimum of two (2) years’ experience in Pediatrics.
- Required Other Work experience requirements may be waived for associates engaged in Florida's CMS contract that worked in a similar capacity for Florida's Department of Health in 2018.
- Intermediate Ability to multi-task
- Intermediate Ability to work independently
- Intermediate Demonstrated time management and priority setting skills
- Intermediate Demonstrated interpersonal/verbal communication skills
- Intermediate Ability to create, review and interpret treatment plans
- Intermediate Ability to implement process improvements
- Intermediate Ability to effectively present information and respond to questions from families, members, and providers
- Intermediate Other Ability to understands the business and financial aspect of case mgmt in a managed care setting
- Intermediate Knowledge of healthcare delivery
- Intermediate Knowledge of community, state and federal laws and resources
- Intermediate Demonstrated written communication skills
- Intermediate Demonstrated customer service skills
Licenses and Certifications:
A license in one of the following is required:
- Required Licensed Registered Nurse (RN)
- Required Other Maintain required contact hours to fulfill regulatory requirements
- Preferred Certified Case Manager (CCM)
- Required Intermediate Microsoft Word
- Required Intermediate Microsoft Excel
- Required Intermediate Microsoft Outlook
- Required Intermediate Healthcare Management Systems (Generic)
- Required Other In the state of NY, associates may be required to be proficient in one of two buckets of languages. Bucket one consists of the below:
- Required Bengali
- Required Other Bucket two consists of:
- Required Other Cantonese
- Required Other Fujianese
All your information will be kept confidential according to EEO guidelines.