Coordinate all aspects of the care of individual members. Ensure proper utilization of services and resources. Review of prior authorization requests for appropriateness of care within established evidence base criteria sets. Provide assistance within, between, and outside of facilities. Facilitate outstanding member care using fiscally responsible strategies. Collaborate closely with physicians, nurses, social workers and a wide range of medical and non-medical professionals to coordinate delivery of healthcare services. Assess the member’s specific health plan benefits and the additional medical, community, or financial resources available
Collect and assess member information pertinent to member’s history, condition, and functional abilities in order to develop a comprehensive, individualized care plan that promotes wellness, appropriate utilization, and cost-effective care and services.
Develop, implement, and coordinate case management action plan for achieving specified member goals as determined by the case management plan. Coordinate necessary resources to achieve goals and objectives. Accurately document case notes and letters of explanation which may become part of legal records.
Monitor and evaluate appropriateness of case management action plan, assess progress toward meeting goals, and modify the plan to help achieve desired member outcomes.
Perform concurrent review of members admitted to hospitals. Maintain telephone contact with the hospital utilization review personnel to assure appropriateness of continued stay and level of care. Identify cases that require discharge planning, including transfer to skilled nursing facilities, rehabilitation centers, home health or hospice services.
Review referral and preauthorization requests for appropriateness of care within established evidence-based criteria sets.
Identify and negotiate with appropriate vendors to provide services. When appropriate, negotiate discounts with non-contracted providers and/or refer such providers to Provider Network Department for contract development.
Serve as primary resource to member and family members for questions and concerns related to the health plan and in navigating through the health systems issues.
Interact with other PacificSource personnel to assure quality customer service is provided. Act as an internal resource by answering questions requiring medical or contract interpretation that are referred from other departments, as well as physicians and providers of medical services and supplies. Assist employers and agents with questions regarding healthcare resources and procedures for their employees and clients.
Identify high cost utilization and prepares written summary for monthly Large Case Report.
Assist Medical Director in developing guidelines and procedures for the Health Services Department.
Act as backup for other Health Services Department staff and functions as needed.
Serve on designated committees, teams, and task groups, as directed.
Represent the Heath Services Department, both internally and externally, as requested by Medical Director.
Meet department and company performance and attendance expectations.
We would all like to believe that the work we do matters. And at PacificSource, our employees know they help people get the healthcare they need. We believe our employees are the key to our company’s success, which is why we extend the same care and consideration to our staff as we do to our customers.
Building on a tradition of exceptional customer service and community involvement that start...ed in 1933, we put a human face on health insurance and benefits administration—every day.
- We are committed to doing the right thing.
- We are one team working toward a common goal.
- We are each responsible for our customers’ experience.
- We practice open communication at all levels of the company to foster individual, team and company growth.
- We actively participate in efforts to improve our many communities-internal and external.
- We encourage creativity, innovation, continuous improvement, and the pursuit of excellence.