Description: Position Purpose: The Case Manager/Care Coordinator II is responsible for the coordination of services and cost effective management of health care resources to meet individual members' health care needs and promote positive health outcomes. Acts as a member advocate and a liaison between providers, members and HN to seamlessly integrate complex services. Case Management services are generally focused on members who fall into one or more high risk or high cost groups and require significant clinical judgment, independent analysis, critical-thinking, detailed knowledge of departmental procedures, clinical guidelines, community resources, contracting and community standards of care. Case Management includes assessment, coordination, planning, monitoring and evaluation of multiple environments. Manages individual member cases by coordinating the provisions of services, assuring the cost-effective utilization of health care resources to meet individual members' health care needs and promote positive health outcomes. Significant clinical judgement, independent analysis, critical-thinking, detailed knowledge of departmental procedures, clinical guidelines, community resources, contracting and community standards of care are applied during case management activities. The case manager/care coordinator acts as a member advocate and a liaison between providers, member and HN to seamlessly integrate complex services. Screens members for possible case management services. Participates in programs to proactively identify members at risk who are appropriate for case management services. Reviews, screens and prioritizes cases for possible case management services. Expedites access to appropriate care for members with urgent or immediate needs using expedited review process. Performs comprehensive case assessment. Acquires appropriate clinical records, clinical guidelines, policies, EOC, Benefit Policy and coding guidelines. Performs research and analyzes on complex issues. Assesses the member's current health status, resource utilization, past and present treatment plan and services; prognosis, short and long term goals, treatment and provider options. Using professional judgement, independent analysis and critical-thinking skills applies clinical guidelines, policies, benefit plans, etc to determine the appropriate level of care, intensity of service, length of stay and place of service. Identifies existing problems; anticipates potential problems and acts to avoid them. Develops plan of care based upon assessment with specific objectives, goals and interventions designed to meet member's needs. Identifies appropriate health care resources based on member's medical needs, including but not limited to evaluating contracts and negotiating with facilities/vendors. Works with the member/family, provider(s), and other members of the health care team to develop a plan of care that enhances the clinical outcome while maximizing the member's benefits. Applies evidence-based guidelines when available. Effectively utilizes community resources and care alternatives. Implements and coordinates interventions and other activities that lead to the accomplishment of goals established in the case management plan. Continually reassesses services delivered to the member to determine if the goals of the plan of care are being met, whether the goals continue to be appropriate and realistic, and what actions may be implemented to enhance positive outcomes. Monitors information from all relevant sources about the case management plan and interventions to determine the plan's effectiveness. Revises care plan when goals are met, new needs are identified, or changes in interventions are made. Performs evaluation in multiple environments including process and relationships, health care management, community resource and support, service delivery, psychosocial intervention and rehabilitation. Closes cases according to the defined case closure procedure in a timely manner, and in accordance with guidelines established. Other Components of Case Management Develops appropriate documentation and correspondence reflecting determination. Assures accuracy, completeness and conformance to standards. Recognizes potential quality care concerns and refers as appropriate. Identifies and refers members who may benefit from disease management. Identifies potential reinsurance cases and notifies the appropriate department according to policy and procedure. Identifies potential TPL/COB cases, investigate TPL/COB issues and notify the appropriate internal departments. Collaborates and communicates with hospitalists, attending physicians and utilization management staff and other health care professionals when appropriate. Identifies cases needing Medical Director review or input. Presents cases to Medical Director for potential review or determinations when needed. Refers potentially inappropriate resource utilization or quality related concerns to Medical Directors. Performs prospective, concurrent and retrospective reviews and first level determination approvals for assigned members, as appropriate, or refers reviews to appropriate associate. Utilizes considerable clinical judgement, independent analysis, critical-thinking skills and detailed knowledge of medical policies, clinical guidelines and benefit plans to complete reviews and determinations within required turnaround times and regulatory requirements. Works closely with delegated or contracted providers, groups or entities (as assigned) to assure effective and efficient care coordination. Evaluates case management programs of delegated entities. Assesses contracted provider performance against goals on a regular basis. Makes recommendations regarding oversight or joint-management of members. Other Responsibilities: Meets or exceeds established performance goals including but not limited to quality, productivity, turn-around time. Prepares reports, data or other materials for committee presentation. Provides feedback on the effectiveness of policies and procedures. Effectively applies, interprets and communicates policies, procedures, clinical guidelines, medical policy, regulations and standards. Reports suspected fraud and abuse as per company policy. Maintains confidentiality of all PHI in compliance with state and federal law and Health Net Policy. Performs all other duties as assigned.