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TriWest Healthcare Alliance · 1 month ago

Case Manager (RN, LCSW or Clinical Psychologist)

United States

Full-time

Remote

Entry, Mid Level

$83K/yr - $88K/yr

2+ years exp

TriWest Healthcare Alliance is on a mission to serve America's heroes by connecting them to healthcare in the community. The Case Manager is responsible for providing case management services to TRICARE beneficiaries, including screening referrals, developing care plans, and monitoring outcomes.

Health Care

No H1B

Security Clearance Required

U.S. Citizen Only

Responsibilities

Applies knowledge of HIPAA privacy and security regulations as well as URAC accreditation standards to ensure compliance in daily practice

Screens beneficiary needs and circumstances with predetermined program criteria to determine appropriateness for case management. Identifies beneficiaries at high-risk for significant adverse health outcomes and with high-cost, clinical and psychological factors impacting care

Documents the process by providing the case management enrollment information and acceptance letter to the beneficiary. Provides timely decision of acceptance into the case management program and completes appropriate notifications

Completes comprehensive case management assessments. Develops individualized case management care plans to assist beneficiaries with obtaining access to quality care in a cost-effective manner. Obtains necessary agreements for obtaining protected health information as needed. Makes the care plan available to the Primary Care Manager or Behavioral Health provider for information and input

Reassesses and monitors care plans for adjustments on a monthly basis, at a minimum, to address newly-identified needs, services, treatment, and funding options. Documents changes in the care plan maintained in the medical management system

Evaluates case management outcomes, assessing the individual beneficiary's satisfaction and compliance with the care plan

Prepares and presents cases involving high-profile or sensitive issues to the Medical Director for review

Functions as an advocate for the beneficiary by ensuring access to necessary care and maintaining Beneficiary’s safety, locating specialized services outside the network by identifying providers, exploring nature of services offered, and facilitating process

Supports beneficiaries by providing TRICARE and community resource information and internal care referrals as needed to meet care plan goals

Understands, administers the TRICARE Specialty Program benefits, including program registration, enrollment, authorizations, and screening for high risk factors indicating appropriateness for catastrophic case management services

Monitors and provides direction to non-clinical staff

Regular and reliable attendance is required

Qualification

Licensed Clinical Social WorkerRegistered NurseClinical PsychologistURAC-recognized certificationCase Management experienceHIPAA complianceTRICARE policiesEmpathyCommunication skillsProblem-solving skillsOrganizational skillsTeam player