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Case Manager (Kapolei)


Posted: 10/2/2019
Job Reference #: 5000529634406

Job Description

Employment Type


Exempt or Non-Exempt


Job Summary

Engages members by utilizing the nursing process, motivational interviewing, critical thinking and clinical knowledge to identify health risks, developing appropriate action plans, and implementing a plan to close the gaps and reduce the risk. Data from multiple sources will be leveraged to develop the nursing plan of care based on working with healthcare providers, members and or authorized representative ensuring understanding of medical requirements, treatment options, health plan benefits, available resources and minimizing the fragmentation of care services and adverse outcomes.

Job is required to work primarily from home or in a remote office environment and infrequently at various unassigned workstations located throughout applicable HMSA department(s) mainly for in-person and on-site meetings with internal contacts.

Minimum Qualifications

  1. Associates degree in Nursing and one year of clinical experience in medical-surgical, community/home health care, case management, and equivalent experience reviewing patient medical care and services.
  2. Current RN license in good standing in the State of Hawaii
  3. Current American Heart Association Healthcare Provider certification
  4. Valid driver's license, access to an automobile with current license, registration and no fault insurance. Requires safely operating an insured automobile for travel to off-site locations to conduct and accomplish business related activities.
  5. Good working knowledge of Microsoft Office suite
  6. Experience with electronic medical records
  7. A strong knowledge and expertise in case managing complex cases with minimal supervision.
  8. Documentation skills, analyzing information, decision making, research skills, verbal communication, written communication, interpersonal skills, resolving conflict, and integrity.
  9. Well organized, ability to multitask and work independently to promote flexibility and teamwork.
  10. Effectively to work in a fast paced environment and adjust to rapid change.
  11. Provide excellent customer service to external and internal customers.
  12. Excellent analytical and problem solving skills in order to judge medical necessity and appropriateness of patient services and treatments on a case by case basis.
  13. Must be able to effectively work in a fast paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time.
  14. Maintains confidentiality of patient information according to Federal (HIPAA), organizational, and departmental policies.
  15. Effectively communicate effectively with providers and other health care team and develop strong and collaborative working relationship.

Duties and Responsibilities

  1. Engagement, Assessment and Planning
    • Engages members in the case management program (outreach and successful enrollment) using diagnostic cost group classifications or other tools which identify the relative risk score and illness burden. Identifying catastrophic health care users with significant health care costs is a priority.
    • Conducts and documents a comprehensive assessment of the member's health psych/social needs, including health literacy and deficits. Gathers clinical information which includes past medical history, medications, physical/psychosocial factors, cultural influences, evaluation of health care barriers to include: available support systems, available benefits, community resources, financial, transportation, employment, housing, educational, and health information as appropriate to develop and create an effective care plan and medication compliance.
    • Utilizes extensive case-management clinical knowledge and experience to coordinate integrated care-plan in collaboration with Primary Care Physician (PCP), specialists and other healthcare providers/vendors. Goals developed will be prioritized, action-oriented and time-specific to stabilize the complicated health care condition.
    • Executing the transition of care and facilitates review of service request containing all appropriate information (clinical, medical policy, contact/complex benefit structure, FDA treatment, clinical trials and drugs) via collaboration with Medical Management for a medical necessity determination.
    • Determines need for and conduct inter-disciplinary and/or family.
  2. Implementation / Evaluation
    • Analyze situations and determine proper course of action by making critical decisions and utilizing independent clinical judgment.
    • Proactively identifies member care needs and develops and communicates a collaborative Plan of Care. Ensures member is progressing towards desired outcomes by monitoring care through ongoing assessments and/or member records. Identifies and provide educational and community resources, support groups, medication reconciliation, pharmacy program and financial assistance and alternative payers (COBRA, SSDI etc.). Assists with planning and coordination including out of state services, follow-up appointment with treating physician, and assists with self-management of serious or complex conditions.
    • Communicates with providers and develops collaborative relationships.
    • Interacts with the member as needed and necessary via telephone and face-to-face visits and provides support until the member and their authorized representative are able to manage and maintain the health of the member.
    • Documents the necessary communication and follow up with the member, family, physicians, and other health care providers to ensure the member's progression in meeting the established care plan goals.
    • Evaluates the extent to which the established goals in the plan of care have been achieved.
    • Evaluate member and provider satisfaction and quality of care provided.
  3. Miscellaneous Support
    • Participates in the preparation and on-site reviews for Employer/Group accreditation audits.
    • Responsible for completion of documentation review and self-audit as assigned by management.
    • Assists in claims inquiries and resolution.
    • Participates in meetings with Providers and or Provider group leaders to improve quality and effectiveness of services provided to members.
  4. Other duties as assigned