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Job Posting

Case Manager/Care Coordinator ll

Company: Health Net, Inc.

Location

Job Description:

Health Net, Inc. (NYSE: HNT) is among the nation's largest publicly traded
managed health care companies. Health Net's mission is to help people be
healthy, secure and comfortable. The company's POS, HMO, insured PPO,
behavioral health and government contracts subsidiaries provide health
benefits to more than 7 million individuals. For more information on Health
Net, Inc., please visit the company's Web site at www.healthnet.com

JOB SUMMARY:
INTEGRATED TELECOMMUTING OPTION - Phoenix, AZ-Based Positions Only - Multiple RN Opportunities

The Case Manager/Care Coordinator II is responsible for the coordination of
services and cost effective management of health care resources to meet
individual members' health care needs and promote positive health outcomes.
Acts as a member advocate and a liaison between providers, members and HN
to seamlessly integrate complex services. Case Management services are
generally focused on members who fall into one or more high risk or high
cost groups and require significant clinical judgment, independent
analysis, critical-thinking, detailed knowledge of departmental procedures,
clinical guidelines, community resources, contracting and community
standards of care. Case Management includes assessment, coordination,
planning, monitoring and evaluation of multiple environments.

ESSENTIAL DUTIES AND RESPONSIBILITIES:
• Participates in programs to proactively identify members at risk who are
appropriate for case management services.
• Reviews, screens and prioritizes cases for possible case management
services.
• Expedites access to appropriate care for members with urgent or
immediate needs using expedited review process.
• Acquires appropriate clinical records, clinical guidelines, policies,
EOC, Benefit Policy and coding guidelines.
• Assesses the member's current health status, resource utilization, past
and present treatment plan and services; prognosis, short and long term
goals, treatment and provider options.
• Develops plan of care based upon assessment with specific objectives,
goals and interventions designed to meet member's needs.
• Works with the member/family, provider(s), and other members of the
health care team to develop a plan of care that enhances the clinical
outcome while maximizing the member's benefits.
• Performs evaluation in multiple environments including process and
relationships, health care management, community resource and support,
service delivery, psychosocial intervention and rehabilitation.
• Closes cases according to the defined case closure procedure in a timely
manner, and in accordance with guidelines established.
• Identifies potential reinsurance cases and notifies the appropriate
department according to policy and procedure.
• Identifies potential TPL/COB cases, investigate TPL/COB issues and
notify the appropriate internal departments.
• Identifies cases needing Medical Director review or input. Presents
cases to Medical Director for potential review or determinations when
needed.
• Refers potentially inappropriate resource utilization or quality related
concerns to Medical Directors.
• Performs prospective, concurrent and retrospective reviews and first
level determination approvals for assigned members, as appropriate, or
refers reviews to appropriate associate.
• Utilizes considerable clinical judgment, independent analysis,
critical-thinking skills and detailed knowledge of medical policies,
clinical guidelines and benefit plans to complete reviews and
determinations within required turnaround times and regulatory
requirements.
• Works closely with delegated or contracted providers, groups or entities
(as assigned) to assure effective and efficient care coordination.
• Maintains confidentiality of all PHI in compliance with state and
federal law and Health Net Policy.

REQUIREMENTS:
Education:
Graduate of an accredited nursing program. Bachelor's degree preferred for
nursing graduates.

Certification/License:
• Valid & active state of Arizona Registered Nurse license required.
• Case Management certification preferred.

Experience:
• Minimum three years clinical experience required.
• Two to three years Case Management experience required.
• Health Plan experience preferred.

Knowledge, Skills & Abilities:
• Strong knowledge of NCQA, federal and state regulations/requirements.
• Bilingual English/Spanish desired.
• Demonstrated ability for assessment, evaluation and interpretation of
medical information, and care planning.
• Possess a high level of understanding of community resources, treatment
options, home health, funding options and special programs.
• Extensive knowledge of the management of chronic conditions.
• Experience using standardized clinical guidelines required.
• Able to operate PC-based software programs including proficiency in
Word, Excel, PowerPoint, Access and Project.
OR
Any combination of academic education, professional training or work
experience, which demonstrates the ability to perform the duties of the
position.

For immediate consideration apply at: www.careersathealthnet.com.
Click on Find a Career; locate this position by Job Number 09001342; click on Search; click on the job title when it appears (toward bottom of page); click on the Apply On Line button.

On behalf of Health Net, thank you for your application.

Additionally, if anyone that you know may have interest in Health Net's
Non-Clinical Case Management/Disease Management Assistant II opportunities,
please request that they apply to www.careersathealthnet.com, referencing
09001343 Job Requisition Number.

Health Net, Inc. supports a drug-free work environment and requires
pre-employment background and drug screening.

Health Net and its subsidiaries are an Equal opportunity/Affirmative Action
Employer M/F/V/D.

 

Please mention this ad on MinorityNurse.com when applying.

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