Care Specialist

Summary:

• Responsible for the execution of the non-clinical aspects of the Care Management process.
• Ensure information is appropriately entered in the system to effectively execute member care plans, originate authorizations, request clinical information, perform case research, and essentially execute all behind the scenes desk-level procedures of a case.
• Work seamlessly with the Care Specialists, Care Managers and Social Workers (and other clinical staff) to ensure everything that a participant needs to tend to their health is addressed.
• Provide confidential administrative support and assistance to the department and support the department in all aspects of daily project operations.
• Assist the entire Care Management interdisciplinary team in managing members with Care Management needs.
• Provide telephonic outreach to members that have been identified for care management and ensure members’ needs are supported throughout the duration of member enrollment to the program, by completing screenings with members, coordinating with Care Manager on members’ care plan, making appropriate referrals to the interdisciplinary care team, coordinating post-acute services on behalf of members, assisting with community resource needs and more.

Responsibilities:

• Work collaboratively, as a critical component of the Medical Management team, to facilitate all clerical and administrative processes and activities.
• Perform accurate and timely intake and data entry for all Care Management requests and referrals for all lines of business, upon receipt of inbound requests, via call, fax and web portal, in accordance with departmental policy and regulatory requirements.
• Perform member telephonic outreach for program enrollment with the goal of retaining members in the Care Management Program.
• Triage cases and assign receipts to appropriate teams.
• Communicate and/or respond to inquiries from providers, facilities and members.
• Initiate completion of member and provider correspondence and verbal outreach according to departmental guidelines.
• Enter and maintain documentation in electronic record, meeting defined timeframes and performance standards.
• Provide phone queue management for both incoming and outgoing calls.
• Perform other related projects and duties as assigned.
• Under the direction of a Care Manager, manage caseload and update care plans for low and moderate risk members in collaboration with the clinical team.
• Support care interventions including making doctor’s appointments, health coaching, referrals to internal and external resources, assist with transportation issues.
• Leverage motivational interviewing skills and a member-centric approach to identify members’ needs, prioritize and support care plan.
• Perform a wide range of research and educational outreach activities to encourage healthy behaviors, such as outreaching to identified members who need a primary care provider or who may have gaps in care related to
  recommended tests or provider visits and facilitate gap closure and receipt of evidence-based care.
• Adhere to processes for collecting member-specific clinical and demographic data from providers and other entities as required by clinical staff.
• Support communication and coordination with delegated entities, as necessary.
• Coordinate directly with community-based organizations and agencies to identify available and/or alternative resources for a wide range of concerns, including home safety, financial assistance, caregiver support and transition
  assistance.
• Actively participate in assigned committees and projects.
• Additional tasks and duties as required.
• Required to work weekends, nights and holiday as necessary.