JOB SUMMARY:

The Complex Case Manager (CCM) will identify, monitor, manage, and evaluate the delivery of health services to Community members with chronic, medically complex or catastrophic conditions in both acute and non-acute settings. The CCM will coordinate the care of a member with the involvement of the member, their PCP, Specialist and other provider. The CCM will identify the most medically appropriate therapeutic intervention to maximize the clinical outcomes associated with chronic medically complex diseases with potentially catastrophic outcomes. The CCM will perform a telephonic assessment and create an individualized plan of care and discharge needs assessment based on member needs utilizing available benefits and resources. The CCM will authorize services for active members admitted to the case management program at all levels of care, including outpatient, inpatient, and transitional levels of care. The CCM will help ensure proper data entry of authorization in the managed care platform, and initiate the approval process for requested services/treatments utilizing nationally recognized evidenced based clinical criteria and/or internal policys, protocols, and procedures. The CCM will use nursing knowledge, critical thinking and background to screen and review clinical information for the most appropriate service areas within Community; making referrals to community health workers, high risk perinatal and disease management teams as well as external resources. The CCM will work closely with the medical directors and refer requests that do not meet medical necessity criteria. The CCM will initiate request for single case agreements and or letters of agreement for members requiring out of network providers. The CCM will be responsible for meeting required performance and quality metrics and ensure reviews are completed within established regulatory, and state requirements.

MINIMUM QUALIFICATIONS:

• Education/Specialized Training/Licensure: Registered Nurse ( RN) , current unrestricted license in the state of Texas, BSN preferred, CCM required or must receive within 18 months of employment.
• Work Experience (Years and Area): 5 years clinical experience in an acute care setting preferred. At least 2 years insurance related experience in a managed care environment.
• Software Operated: Microsoft Office (Word, Excel, Outlook)

Special Requirements:

• Communication Skills:Above Average Verbal (Heavy Public Contact)
• Other Skills: Analytical, Medical Terms, MS Word
• Work Schedule: Flexible
• Other Requirements: Strong written and verbal communications skills. Demonstrated ability to motivate others. Use of personal car is required.