Position Description:

Case Management is a collaborative process which includes assessment, planning, implementation, coordination, monitoring, education and evaluation of options and services to meet a member’s health needs to promote quality, cost-effective outcomes.

The APS Care Manager serves a central position as a link between the member, provider(s), the payor, and the community. In this role, the Care Manager seeks to enhance treatment outcomes and reduce the risk of future utilization by appropriate referral, triage and education, while simultaneously containing unnecessary costs. This goal is achieved by decreasing service fragmentation while coordinating benefits of the health care plan.

APS Healthcare employees are expected to maintain a positive work atmosphere through communicating and behaving in a manner that is courteous and respectful of customers, clients, co-workers, and supervisors.

ESSENTIAL JOB FUNCTIONS:

The Care Manager will:

1. Assess and evaluate relevant member information related to the current treatment plan to identify barriers, to clarify or determine realistic goals and objectives, and to seek potential beneficial alternatives.

2. Work with the member to develop a treatment plan that enhances outcomes and reduces payor liability. Initiates and implements plan modifications as necessary through monitoring and re-evaluation to accommodate changes in treatment progress.

3. Facilitate communication and coordination of delivery services among all team members including the member, provider and other involved parties.

4. Advocate for the client’s individualized needs and goals throughout the case management process. Educate the client to become empowered and self-reliant by reviewing the optimum coordination of funding, treatment alternatives, timelines, and coordination of health services.

5. Provider and community referrals.

6. C3 and/or other system proficiency for case management documentation following NCQA and URAC standards.

7. Maintain an intimate working knowledge of clinical guidelines (APS, ASAM, M&R, URAC), and effectively utilize care management documentation systems.

6. Maintain a strong working knowledge of local and state resources for behavioral health treatment.

7. Facilitate growth in Case Management service delivery and quality by actively seeking to enhance products, services, and department efficiency.

8. May conduct certification reviews for pre-admission, continued stay and retroactive reviews. May coordinate appeals, denials with physician advisors.

9. Provide services within the scope of practice defined by current education, certification or licensure, community and published standards.

10. Organize personal workload and contribute time and effort to the team workload by:

A. Ensuring that phone calls are returned by the next business day.
B. Completing all case work and reporting in a timely manner.
C. Maintaining a thorough knowledge of and compliance with policies, procedures and QA requirements.
D. Attending and/or participating in the majority of staff/team meetings.
E. Identifying, evaluating, and providing feedback on departmental workflows to increase efficiency.
F. Participating in Policy and Procedure, QA, and/or committees as assigned.

11. Maintain a strong working knowledge of the customer base and their provider network.

Minimum Qualifications:
Bachelor’s (or higher) degree in a health-related field and licensure as a health professional in Hawaii; or

RN licensure and three (3) years clinical practice experience.

Minimum Experience:
Minimum of three years experience in direct inpatient and outpatient mental health clinical care.

Utilization management and case management experience preferred.

Other Experience:
Excellent clinical assessment, crisis intervention, and therapeutic skills with mental health and/or substance use disorders.

Skilled in balancing clinical and financial issues in care management decisions, adept in directing clinical work teams and gathering critical reporting data.

Independent, highly organized team player, able to handle multiple tasks simultaneously.

Knowledgeable in case management software systems and Microsoft Office suite of applications.

Excellent communication skills.

Skill in Internet search activities is desirable.

Ability to operate copier, fax machine, and telephone.

Must be able to access, research and extract information from printed and online resources.

The above statements are intended to describe the general nature and level of work being performed. They are not intended to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel as classified.