Role:Dedicated Case Manager
Humana’s dream is to help our members and our own associates achieve lifelong well-being. Use your clinical experience to work with patients and providers in a nontraditional environment where your knowledge will make a difference. Our associates know their work is vitally important; we strive to ensure we provide perfect service with one-on-one member interactions as a coach, personal nurse, or clinical advisor. Humana’s Perfect Service® means getting the basics done right, delivering value and quality, providing guidance on needs, and being engaged with our members. We want to help our members make the right choices to live life fully. We begin that process by connecting our members with an associate who cares.
The principal clinical Humana representative for Humana members in an engaged provider group (defined as a contracted Humana MSO, IDS, Medical Home or Model Practice) to coordinate care, to help clarify clinical benefits and/or to direct to internal Humana resources on non-clinical matters (e.g., claims).
- Identification and steerage of Humana members needing discharge planning services, admissions to subacute facilities and/or ambulatory service needs.
- Direct referrals to participating subspecialists outside of the engaged provider group.
- Identification of and direct referral of members with a readmission to a provider group PCP for follow-up evaluation.
- Identification and direct referral of members with more than one ER visit within a 30-day period to a provider group PCP for follow-up evaluation.
- Identification and direct referral of members with a gap in prescription coverage and/or where their prescription pattern suggests a potential problem to a provider group PCP for a follow-up evaluation.
- Direction of members into a Humana Senior Case Management, Disease Management, Lifesynch and/or HumanaCares program(s) as necessary
- In collaboration with the Stars Strategy Director, identification of members with gaps in CMS Stars-HEDIS measures and calling such members on behalf of the provider group PCP to schedule screening appointments .
- Interaction with members to coordinate any other care needs
- Ensuring the appropriate coding of member conditions.
- Assisting the Provider Engagement Clinical Leader and Regional Medical Director in reporting back to the provider group on the critical utilization and quality key performance metrics relevant to members being seen within the group.
- Builds Trust: Consistently models and inspires high levels of integrity, lives up to commitments, and takes responsibility for the impact of one's actions.
- Accountability: Meets established expectations and takes responsibility for achieving results; encourages others to do the same.
- Customer Focus: Connects meaningfully with customers to build emotional engagement and customer advocacy. Simplifies complexity and integrates internal efforts to deliver an optimal customer experience.
Executes for Results:Effectively leverages resources to create exceptional outcomes, embraces change, and constructively resolves barriers and constraints.
BSN or MSN
- 5 to 7 years of direct managed care experience in UM and/or CM.
- 5 years of recent direct patient care experience in either an Integrated Delivery System, an MSO or an acute IP facility.
- Excellent and proven ability to communicate, problem-solve, negotiate and resolve difficult clinical and social issues with patients, patients’ families and physicians efficiently and effectively.
- Proven ability to work successfully within multidisciplinary teams as well as independently.
Proven ability to work virtually.
Strong track record of supervisory management experience.
- Previous project management experience including database management skills (e.g., Excel).
- Certified Case Manager (CCM).
Humana is an organization with careers that change lives—including yours. As an innovator in the fast-paced industry of healthcare, we offer our associates careers that challenge, support and inspire them to use their passion for helping others and to lead their best lives. If you’re ready to help people achieve lifelong well-being, and be a part of an organization that is growing and poised to make an impact on the future of healthcare, Humana has the right opportunity for you.
Apply now, or join our Talent Network so you can stay informed and up to date on what’s happening at Humana.
Title: RN Dedicated Case Manager - Rogers, Arkansas
Requisition ID: 175853