Job Description

Summary

Responsible for providing case management services and support to improve health outcomes via a coordinated approach.  The Case Manager works in collaboration and continuous partnership with patients and their family members, as well as pcp, specialists, clinic, hospital, and post-acute partners, along with community resources, to achieve the desired outcomes. Using a defined process to identify patients/members at risk for poor outcomes, the Case Manager establishes care plans and goals, and coordinates care and services throughout the continuum of care with the goal of maximizing member health and well-being, improving adherence to health programs, and reducing health care costs.  The Case Manager must be highly collaborative with strong customer service skills and be able to demonstrate the ability to actively engage patients and providers in positive relationships. Must also be able to demonstrate the knowledge and skills necessary to provide care management services appropriate to the member being served.

Reports to:  Director, Health Services  
Location: Houston, TX area; will consider remote deployment on a case by case basis

Education: Registered Nurse (RN)

LICENSES/CERTIFICATIONS:

Registered Nurse (RN)  with active license in the state of Texas or Compact state.

Certification in Case Management preferred (CCM or ACM)

EXPERIENCE :

• Minimum 2 years in case management or care coordination required; chronic disease management or population health preferred
• Managed care experience preferred
• Strong ability to demonstrate knowledge of ACO initiatives and care management processes
• Understanding of NCQA and CMS care management guidelines preferred
• Experience working in interdisciplinary teams
• Computer proficiency required
• Strong oral and written communication skills required
• Effective oral and written communication skill
• Some travel in the Houston metro area may be required
• Remote deployment will be considered

SKILLS

• Knowledge of healthcare delivery
• Ability to work in a fast paced environment with changing priorities
• Ability to work with others in a matrixed environment
• Demonstrated written communication skills
• Demonstrated time management and priority setting skills
• Demonstrated problem solving skills
• Demonstrated organizational skills 
• Demonstrated ability to converse with and collaborate with physicians and other healthcare personnel
• Reasoning ability to identify and define problems, collect data/information, establish facts, and draw valid conclusions, makes decisions and implements changes related to TDI and Federal regulations

RESPONSIBILITIES

• Provides primary care management interventions (screening, assessment, care planning, implementation of interventions) to identified members enrolled in the care management program
• Identify members at risk for poor outcomes, or experiencing poor coordination of services, who would benefit from more intensive follow-up and care coordination.
• Conducts a thorough assessment of the member’s current status, with attention to the physical, behavioral, social and economic care needs
• Coordinates a comprehensive plan of care for the high-risk, high-utilizing population, and collaborates with clinical staff and the patient/family in the development and execution of the plan of care, and achievement of goals.
• Provides proactive outreach to members to include telephonic, internet, or face-to-face encounters.
• Works seamlessly with other health management disciplines to assist members in problem-solving potential issues related to financial and psychological barriers, as well as problems with the overall system of care.
• Improves continuity of care by managing and facilitating relationships with post-acute providers, physicians, and community resources.
• Conducts chronic disease and self-management education and support to improve comprehension, health literacy and adherence to established plan of care.
• Provides medication management support, including comprehensive medication review and adherence education

• Communicates, collaborates and cooperates with internal and external stakeholders.
• Collaborates effectively with Utilization Management, Quality Management, Pharmacy, Provider relations and other health plan departments
• Adheres to all Compliance/Program Integrity requirements.
• Complies with HIPAA Regulations
• Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency
• Supports department-based goals which contribute to the success of the organization

TECHNICAL SKILLS

• Microsoft Office products
• EZCap experience preferred

About Apex Health Solutions

Apex Health Solutions powers payers and providers choosing to engage in value-based risk contracting. Apex’s unique solutions create alignment between payers and providers, generating unparalleled value. Combined with Apex’s experienced and successful industry leadership, our focal point remains on improvement in patient quality, satisfaction and overall cost of care.

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