Virginia Premier Health Plan, Inc.

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Case Manager II

Case Manager II

Job Locations 
US-VA-Roanoke
Job ID 
2017-4108

Job Description

Overview

Responsible for the timely coordination of quality health care services to meet the member’s specific health care needs in a cost-effective manner to promote positive outcomes. Performs care management for members with complex and chronic care needs by assessing, implementing, coordinating, monitoring, and evaluating plans of care designed to optimize member health care across the continuum and ensuring member access to services appropriate to their health needs.

Medical Management

Medical Management educates members and empowers them to become active participants in their coordinated health care plans. This team of knowledgeable professionals in their field provide services to include Utilization Review, Medical Outreach, Case Management, Disease Management, Credentialing, Social Work as well as Grievance and Appeals.

Responsibilities

  • Create case in Care Management Documentation system for all members identified for case management
  • Obtain verbal consent from member for participation in the case management program
  • Conduct a comprehensive assessment on each member that includes clinical and mental status, clinical history, ADL’s cultural and linguistic needs, and life planning
  • Assess resource utilization and cost management
  • Develop individualized plan of care with input from member/family that includes long and short-term goals
  • Collaborate with PCP and other members of the health care team in plan of care
  • Identify resources to be utilized, including the appropriate level of care
  • Identify problems that require case management intervention
  • Identify barriers to care such as member’s lack of understanding, motivation, financial, transportation needs and over/under utilization of services
  • Schedule follow up and communication with member to monitor the quality of care to determine if the plan of care is being achieved
  • Coordinate and modify resources and services needed to evaluate the effectiveness of the plan of care
  • Assess progress against case management plan and goals and modify as needed
  • Assists in data collection to evaluate the access, cost and quality of care provided
  • Practices in accordance with applicable local, state and federal laws which govern confidentiality and medical information privacy regulations (HIPAA)
  • Knowledgeable of accreditation and regulatory standards
  • Seeks appropriate resources and consultation to help formulate ethical decisions
  • Acts as an advocate for a member’s health care needs
  • Participates in VPHP’s ongoing quality improvement process
  • Participates in continuing educational activities as appropriate
  • Participates in case management rounds/meetings

Qualifications

MINIMUM REQUIREMENTS

  • Registered Nurse licensed in Virginia
  • Bachelor’s degree in related field, preferred
  • Certified Case Manager, preferred

SPECIAL KNOWLEDGE AND/OR SKILLS

  • Patient care evaluation skills and the ability to communicate well (written and verbal) with all levels of management, medical staff and employees.
  • Computer literate with working knowledge of Microsoft Office and various computer software programs
  • Working knowledge of resource options, and experience in making appropriate referrals
  • Strong decision making skills, ability to handle multiple priorities

WORK BACKGROUND/EXPERIENCE

  • Minimum of three (3) years clinical experience
  • Experience working with low income and disadvantage populations
  • Minimum of one (1) year recent case management and managed care experience; Two (2) or more years preferred within the last 3-5 years

PHYSICAL REQUIREMENTS

  • Physical health sufficient to meet the ergonomic standards and demands of the position.

About Us

 

Virginia Premier Health Plan, Inc. is a managed care organization which began as a full-service Medicaid MCO in 1995. Partnered with VCU Medical Systems we strive to meet the needs of the underserved and vulnerable populations in Virginia by delivering quality driven, culturally sensitive and financially viable Medicare and Medicaid healthcare programs.  Headquartered in Richmond, VA we also have offices in Roanoke, Tidewater and Bristol with additional satellite locations allowing us to serve over 200,000 members across eighty counties throughout Virginia. 

 

We offer competitive salaries and a comprehensive benefits package to include excellent Medical, Dental and Vision Plans, Tuition Assistance, Infant-At-Work Program, Remote Work options and generous vacation and sick leave policies. Our culture supports an environment where employees can continuously learn and gain professional growth through various development programs, education, exciting projects and career mobility.  

 

All qualified applicants will receive consideration for employment without regard to age, race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status. EOE

 

Our mission is to inspire healthy living within the communities we serve!

 

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