Job description

Our client, a Retail Pharmacy company, is looking for a Care Management Associate for their Jefferson County, KY location.

Responsibilities:

Provide comprehensive healthcare management services to facilitate appropriate healthcare treatment, effectively
Manage healthcare costs and improve healthcare program/operational efficiency involving clinical issues
The Care Management Associate supports comprehensive coordination of medical services including Care Team intake, screening and supporting the implementation of care plans to promote effective utilization of healthcare services.
Promotes/supports quality effectiveness of Healthcare Services.
Fundamental Components:
Responsible for initial review and triage of Care Team tasks.
Identifies principle reason for admission, facility, and member product to correctly apply intervention assessment tools.
Screens patients using targeted intervention business rules and processes to identify needed medical services, make appropriate referrals to medical services staff and coordinate the required services in accordance with the benefit plan.
Monitors non-targeted cases for entry of appropriate discharge date and disposition.
Identifies and refers outlier cases (e.g., Length of Stay) to clinical staff.
Identifies triggers for referral into Client Case Management, Disease Management, Mixed Services, and other Specialty Programs.
Utilizes Client systems to build, research and enter member information, as needed.
Support the Development and Implementation of Care Plans.
Coordinates and arranges for health care service delivery under the direction of nurse or medical director in the most appropriate setting at the most appropriate expense by identifying opportunities for the patient to utilize participating providers and services.
Promotes communication, both internally and externally to enhance effectiveness of medical management services (e.g., health care providers, and health care team members respectively).
Performs non-medical research pertinent to the establishment, maintenance and closure of open cases.
Provides support services to team members by answering telephone calls, taking messages, researching information and assisting in solving problems.
Adheres to Compliance with PM Policies and Regulatory Standards.
Maintains accurate and complete documentation of required information that meets risk management, regulatory, and accreditation requirements.
Protects the confidentiality of member information and adheres to company policies regarding confidentiality.
May assist in the research and resolution of claims payment issues.
Supports the administration of the hospital care, case management and quality management processes in compliance with various laws and regulations, URAQ and/or NCQA standards, Case Management Society of America (CMSA) standards where applicable, while adhering to company policy and procedures.
Technical and Logistical Requirements:
Device & System Navigation: Comfortable setting up and using multiple monitors and navigating multiple applications simultaneously to streamline tasks and improve efficiency.
Communication Tools: Ability to communicate on digital channels such as via email, calendar invites, Teams messaging, and virtual meetings.
Collaboration & Scheduling: Experience with Microsoft Office 365 (Teams, Outlook, Word, Excel, PowerPoint) applications or similar (Google Workspace).
Systems Access & Security: Ability to Log in to secure systems (e.g., VPN, EHR portal), lock a computer screen when unattended, manage strong passwords, and recognize suspicious emails or links.
Troubleshooting & Support: Ability to resolve common technical issues independently, such as: restarting an application when frozen, resolving internet connection issues, and contacting IT for unresolved technical issues.
Future Growth: Openness to learning new skills in the future as the workplace environment evolves
Determines medical necessity/ appropriateness
Facilitates optimal outcomes
Identifies and follow through with continuous quality/ compliance opportunities .
May also include identification of aberrance's and initiation of corrective action
Educates/ empowers customers to ensure compliance, satisfaction and promote patient advocacy
Optimize total costs
Implementation and evaluation of policy based on usage and program directives
Educate/empower colleagues at all levels to enable decision making at most appropriate level

Requirements:

Minimum 3 years of relevant experience
Experience or detailed knowledge of the Foster Care and juvenile justice systems, Adoption Assistance, the delivery of Behavior Health Services, Trauma-informed Care, ACEs, Crisis Intervention services, and evidence-based practices applicable to the Kentucky SKY populations, is required.
2-4 years’ experience as a medical assistant, office assistant.
Computer literacy and demonstrated proficiency is required in order to navigate through internal/external computer systems, and MS Office Suite applications, including Word and Excel.
Effective communication, telephonic, and organization skills.
Familiarity with basic medical terminology and concepts used in care management.
Strong customer service skills to coordinate service delivery including attention to customers, sensitivity to issues, proactive identification and resolution of issues to promote positive outcomes for members.
Ability to effectively participate in a multi-disciplinary team including internal and external participants.
High School Diploma or G.E.D.

Why Should You Apply?

Health Benefits
Referral Program
Excellent growth and advancement opportunities

Care Management Associate

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