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Position Description


Position:  Case Management Analyst
Reports To: 
Division:  zHA Health Affairs (9500)
Location:  Label
Job Code:  030318
Min Salary:   41600
Date Posted:  1/2/2014

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Position Specific Requirements: No position specific requirements

Job Summary
This position functions as a key analyst for developing, reporting and maintaining activities that support health plan initiatives in the enhancement and expansion of Case Management programs. This position is further responsible for collecting, analyzing and maintaining complex data utilizing all lines-of-business, survey instruments, information resources as well as other research methodology necessary to support all Case Management Programs activities. The Case Management Analyst is responsible for providing assistance with the coordination, implementation, and evaluation of the Case Management Programs as well as providing administrative and project management support for all projects of the division. This includes:

• Case Management bi-monthly and monthly reports to Supervisor, Manager, Central Region Regional Executive and Executive Vice President. To establish and maintain efficient execution of all case management processes.
• Independent development and maintenance of information reported to the FEP Directors Office quarterly, critical to the success of the newly implemented FEP Care Management Program.
• Independent development and maintenance of information specific to ABCBS, HA and BlueAdvantage referrals/non-trigger vs. trigger/percent in Case Management to be reported to upper management.
• Determination regarding transmission of disease management referrals to Health Dialog for ABCBS, Health Advantage, and BAA (when purchased).

Nature & Scope
This position reports directly to the Central Region Case Manager Supervisor. This position works closely with the Central Region Medical Affairs Manager, Case Managers, Referral Nurse, and administrative support. In order to enable the Case Management department to meet the URAC Case Management and Core Standards, the Case Management Analyst must have an intrinsic drive to achieve goals and improve upon prior accomplishments while adapting to ever-changing URAC and FEP driven standards and quality improvement efforts through planning, developing processes, and implementing the changes.

The Case Management Analyst provides multiple deliverables, both to internal and external customers. The incumbent must be detail-oriented with exceptional organization skills, personal computer skills, clear and concise communication skills, and data management skills. Confidentiality is required in all work situations. The incumbent independently develops triggers to generate risk assessments for case management referrals, supports medical management and disease management programs for implementation for all lines of business.

The incumbent develops analysis and reports in support of plans performance relative to FEP benchmarks and prior period experience based on data mining and validation. The incumbent will also develop data reports to address anticipated business questions and assist Triage RN and MAM in the gathering and reporting of Care Coordination metrics.
The Case Management Analyst reports to the Central Region Case Manager Supervisor and also receives guidance from the Central Region Manager Medical Affairs. URAC Case Management policy and procedure, and Corporate policy and procedure also guide the employee. This position will utilize the ABCBS, AMISYS, FEP Direct, and AHIN systems. Additionally PC software programs such as Excel, Word, and Power Point is proficient and necessary to support the job requirements of this position.

Maintenance of a fast-paced workload, management of multi-tasks, coordinating efforts among internal and external customers and departments, while responding to requests with timely and quality customer service. This requires a constant realignment of priorities and analysis of workflow and procedures by the incumbent independently planning and implementing those changes.

Skills, Knowledge & Abilities
• Effective interpersonal skills
• Ability to communicate effectively both orally and in writing
• Ability to organize and prioritize work, analyze problems, develop solutions and communicate solutions, recognizing when supervisor or other additional input is needed
• Ability to make decisions based on facts, intuition, or experience, and assume the responsibility for those decisions
• Strong analytical and research skills including the ability to analyze a problem and develop a solution.
• Strong planning, project management, time management, and organizational skills.
• Strong oral and written communication skills.
• Possess ability for attention to extreme level of detail and accuracy.
• Ability to plan and implement the processes establish goals and objectives and methods to achieve these goals.
• Ability to organize and coordinate multi-task workloads for maximum efficiency
• Knowledge of group dynamics
• Ability to work independently.
• Flexibility in performing job duties by reassessing, planning and implementation of duties.
• Must be highly motivated and able to perform job duties independently.
• Ability to communicate in a professional manner.

Minimum Job Requirements

1. High school diploma or equivalent.

2. Meet one of the following:

Bachelor's degree in business or healthcare management related field from an accredited college or university preferred.

Health related non-clerical experience with an insurance, managed care or healthcare organization.

3. Analysis and/or research experience with a complex system technology.

4. Possess in-depth knowledge of the functions of ABCBS, AMISYS, FEP Direct, managed care, insurance or third-party administrative services, or complex claims processing systems technology.

5. Prefer claims, eligibility, or other medical related experience with thorough knowledge of claims processing procedures; and experience with the ABCBS, AMISYS FEP Direct systems or a claims processing equivalent.

6. All applicants must have PC experience with an excellent working knowledge of both Word and Excel and be able to take and pass software proficiency test.

7. Project Management 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.

Performs the following functions critical to the success and workflow of the Central Region Case Management Department:
Collects, analyzes and maintains complex data utilizing all lines of business, survey instruments, information resources and other research methodology.
Responsible for developing analytical queries utilizing the Excel, Tracker, CCA and other systems to support business drivers for case management.
Develop a process to support internal and external business partners (clinical staff, underwriting, marketing, providers, customer service, home health agencies, hospitals, DME, LTAC, physician offices, IV infusion companies, SNF, hospice agencies) on data analysis and reporting in support of benefit cost and/or care management initiatives.
Develops data reports to address anticipated business questions from marketing, underwriting, customer service, claims, and all regions.
Responsible for utilizing data mining techniques to perform complex analyses of claims data.
Utilizes PC software to accumulate, maintain and generate metric reports on Case Management activities.
Provide professional and technical assistance to system, supervisory and management staff of the Central Region Case Management.
Know and implement all required standards  in the URAC accredited Case Management process.
Receives member information, analyze the information, inputs in database, and determine appropriate staff to receive information.
Researches information using various databases such as Customer Service Work Station, Data Warehouse, GCPS, Amisys, FEP Direct, BlueCard, etc.
Builds and maintains positive working relationships with external and internal customers..
Safeguards confidential and sensitive proprietary information.
Independently refers  to case managers/other internal resources for follow-up in regards to questions, complaints, claims/customer service issues, potential health education referrals, members, and providers.
Analyzes system results and reports for accuracy and consistency.
Conducts special data gathering and analysis as required.
Identifies and formulates solutions to business problems through the use of data processing concepts and other concepts as necessary.
Collaborates with external public agencies, vendors, and providers, and internal departments to achieve Case Management goals and objectives. Interaction can be informally through telephone conversations or informal meetings.
Actively participates in the continuous planning process improvement of this position and processes of the division related to Case Management Program procedures.
Responsible for developing the process for training and the ongoing training of team members when indicated.
Develops processes for reporting to supervisor the status of all assigned tasks.
Is knowledgeable of company functions to the level necessary to accomplish assigned tasks and adheres to corporate and regular business systems standards and policies.
Establishes and maintains a cooperative and productive environment with all user division contacts.
Assist customers (internal and external) with issues such as referral inquires, benefits information for case managed clients in all lines of business under the Plan, and services provided related to the Case Management Program.
Provide other duties as assigned by the Case Management Supervisor and/or Manager.

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