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Position Description

HEALTH ADVANTAGE - EXEMPT POSITION DESCRIPTION

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Position:  RN Local Care /Disease Mgmt
Reports To: 
Division:  HA Health Affairs (9500)
Company:  HEALTH ADVANTAGE
Location:  Label
Job Code:  025107
Min Salary:   56800
Date:  3/12/2013

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Position Specific Requirements: N/A


Job Summary
This position is responsible for disease management initiating a collaborative process which assesses plans, implements, coordinates, monitors and evaluates the options and services required to meet an individual’s health needs, utilizing plan benefits and community resources.  The incumbent will utilize communications and available resources to promote quality and cost effective outcomes...

Nature & Scope
The incumbent's charge is to work with referrals from multiple sources to identify appropriate candidates for case management.

Referral sources:
• Utilization Management Vendor
• Hospitals
•Claims
• Trigger Diagnoses
Physicians
• Disease management programs
• Reports
• Medical Records
• Medical Audit and Review
Marketing Groups Agencies
• Customer Service
• Health Assessment
Member


The incumbent will facilitate formation of health care teams to include patients, families/caregivers, physicians, and all other ancillary providers and must have the ability to communicate at all levels, often in a highly charged, emotional environment.

This position works closely with the Quality Program Manager and Medical Directors and Supervisor.


Minimum Job Requirements

1. Arkansas Registered Nurse license and in good standing with clinical
practice experience.
2. CCM Certification required. If certification not obtained prior to employment, must be eligible to sit for exam by the second year of employment and pass certification within  3/6 months in the event the first exam is not  passed
3. A bachelors (or higher) degree in a health related field preferred.
4. Experience in disease management, case management, home health, critical care, medical/surgical, social work, discharge planning or in the insurance field.
5. Marketing experience preferred. 


Security Requirements
This position is identified as level three (3). This position must ensure the security and confidentiality of records and information to prevent substantial harm, embarrassment, inconvenience, or unfairness to any individual on whom information is maintained. The integrity of information must be maintained as outlined in the company Administrative Manual.

Segregation of Duties
Segregation of duties will be used to ensure that errors or irregularities are prevented or detected on a timely basis by employees in the normal course of business. This position must adhere to the segregation of duties guidelines in the Administrative Manual.

PRINCIPAL ACTIVITIES OR ACCOUNTABILITIES (Essential Functions of Job)
1.Supports the physician/patient relationship and plan of care
2. Emphasizes prevention of exacerbations and complications utilizing evidenced based practice guidelines and patient empowerment strategies.
3. Facilitates appropriate cost effective and cost containment measures.
4. Adheres to Enterprise Case Management/Disease Management Standards
5. Practices within the scope of licensure.
6. Cooperates and works effectively with all regional and departmental staff to facilitate services to members and providers of care.
7. Remains current with medical and surgical procedures, products, services and drugs by attending RCM Meeting, conferences, home studies and in-services.
8. Identify appropriate alternate care settings.
9. Participates in quality improvement program.
10. Provides education to provider, community, groups and hospital to facilitate understanding of disease management program.
11. Prompt case findings which are essential to assure timely interaction with members.
12. Contacts member and physician explaining disease management services, ensuring that all parties involved agree to voluntary disease management services.
13. Monitors contracted and case by case negotiations with providers for quality of care issues, cost effectiveness, accessibility, and levels of services provided utilizing JCACHO.
14. Must be able to maintain a minimum caseload at any given time and manage appropriately.
15. Works with high, medium and low risk members as indicated my Risk Stratification measures.
16. Works with customer service department to educate individuals about disease management.
17. Maintains continuous, effective communication between case management/disease management regarding cases requiring both entities.
18. Maintains continuous, effective communication with internal and external vendors.
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