MEDICAL CASE MANAGER
JOB ID 2021-19881
SUMMARY
Responsibilities include reviewing referrals, implementing quality assurance monitors, obtaining alternate resources, screening Contract Health Services specialty care authorizations, reviewing charts and records, tracking and following patients' progress, initiating and maintaining medical and administrative case management documentation.
JOB DUTIES
Routine duties shall include providing health care services to individuals eligible for services in accordance with the self-governance compact and funding agreement between the Cherokee Nation and United States executed under the authority of the Indian Self-Determination and Education Assistance Act. Reviews Contract Health Service referrals for assigned area to screen objectively for eligibility in the program according to applicable rules, regulations and guidelines. Plans, develops and implements quality assurance monitors for the Contract Health Services for assigned area. Maintains patient tracking system and coordinates multi-disciplinary health care team plan for all inpatient CHS patients throughout specialty care episode. Implements and maintains documentation of patient care and progress according to CHS guidelines and requirements. Visits inpatient facilities throughout the region to conduct chart reviews and manage the care of the patient. Makes inquires to obtain alternate resources for services recommended for patients by providers. Consults with staff and multi-disciplinary health care providers as necessary to facilitate appropriate decision-making in referral services. Screens authorizations and reports those exhibiting potential catastrophic cost to the appropriate party (ies). Assists patients and/or family members with appeals process. Evaluates the appropriateness, necessity and efficiency of requested medical services.
QUALIFICATIONS
EDUCATION REQUIREMENT
Associate's degree from two-year college or technical school in Nursing; no substitutions. Bachelor's degree preferred.
EXPERIENCE REQUIREMENT
An additional two years experience in a related field. (Nursing Administration, Medical Case Management, and Discharge Planning)
COMPUTER SKILLS
An individual should have knowledge of Word Processing software.
CERTIFICATES, LICENSES, REGISTRATIONS
Must have a valid driver's license. Possess and maintain an Oklahoma Board of Nursing approved License.
OTHER SKILLS AND ABILITIES
Must have experience in Internet and e-mail. Demonstrated ability in the areas of interpersonal relations, critical thinking, problem solving, and conflict resolution.
OTHER QUALIFICATIONS
Employee must not be and will not be under sanction by the United States Department of Health and Human Services Office of the Inspector General (OIG) or by the General Services Administration (GSA) or listed on the OIG’s Cumulative Sanction Report or the GSA’s List of Excluded Providers; or listed on the OIG’s list of Excluded Individuals/Entities (LEIE).
Position is grant funded and employment is contingent upon funding availability.