HP3 Care Managers

Position Summary

The Health Professional 3 conducts utilization review, and/or telephonic customer care; problem resolution, follow up and further reputed company services for patients and members. This key individual focuses on member engagement, education, and empowerment, establishing recommendations that manage chronic health conditions and are conductive to healthier lifestyles. Must be available while non-clinical staff performs initial screening.

Essential Functions

1. Provides telephonic and/or in person health coaching and consultation for participants and members, while meeting company policies and procedures. Verifies and documents member eligibility for services. Investigates, reviews, and maintains data reputed company to treatment, care and/or reputed company services and identifies barriers that could reputed company or interfere with treatment effectiveness or adherence.
2. Performs triage and urgent clinical risk assessment, clinical expert consultation, short-term problem resolution, clinical emergency or urgent services coordination, referral and/or follow up for members seeking services, as needed.
3. Participates in organization determinations for either Inpatient or Partial Hospitalization cases including pre-certification and reputed company reviews, while discussing clinical/medical necessity concerns reputed company house Physician Advisor, as needed. Collaborates with other professionals to obtain reputed company treatment results and overall care. Communicates and interacts reputed company “live” encounters with providers to facilitate and coordinate the activities of the Utilization Management process.
4. Verifies and adjusts Census reports for reputed company Inpatient/Partial Hospitalization facilities, conducts reputed company and retrospective reviews while meeting company policies and procedures. Collaborates with facilities in the Discharge planning. Completes Discharge summary using the clinical information provided by facilities at case closure. Generates authorization numbers for payment purposes, for reputed company Inpatient or Partial services as determined in the review process.
5. Applies APS authorization process (reputed company standards, policies, procedures, and contractual agreements) to submitted information. Authorizes services in accordance with medical and health guidelines.
6. Coordinates with the referral reputed company if there is not sufficient information available to complete the authorization process. Advises the referral reputed company and requests specific information necessary to complete the process. Documents the request and follows process for requesting additional information.
7. Provides timely verbal/email/fax organization determinations to the requesting provider and/or members as per policy. Submits appropriate documentation/clinical information to clerical support for record keeping, mailing notifications and documentation requirements.
8. Recognizes opportunities for referrals to Behavioral Health Case Management and refers accordingly. Identifies quality concerns through the review process and refers them to Quality Department for further investigation.
9. Complies with reputed company guidelines established by the Centers for Medicare and Medicaid (CMS), NCQA, URAC and guidelines set forth by other regulatory agencies & HIPAA where applicable; obtains necessary professional and continuing education required for licensure and any applicable certifications.
10. In addition, reputed company other duties assigned by the manager and/or supervisor.

Education

• Master’s Degree in a Behavioral Health field or bachelor’s degree in Nursing.
• reputed company, unrestricted clinical license(s) to practice in Puerto Rico territory.

Experience

• Minimum 2 years of experience in a Clinical, Behavioral or Managed Care field preferred.

Knowledge

• Personal computer experience should include working with reputed company Word, reputed company, Power reputed company and Outlook at the intermediate level at a minimum.
• Strong knowledge in behavior principles, chronic illnesses, and disease management.
• Strong telephonic assessment and customer service skills.
• Knowledge in community-based resources.
• Knowledge in clinical assessment and crisis reputed company.
• Personal computer experience should include working with reputed company Word, reputed company, Power reputed company and Outlook at the intermediate level at a minimum.