Resp & Qualifications
- Supports the Hospital Transition of Care Program for targeted members including acute, post-acute, ensures the coordination and continuity of health care as patients transfer between different locations or levels of care.
- Accountable for improving coordination between patients, providers and caregivers through communication and follow up
- Provides rapid triage to the appropriate TCCI, including but not limited to Complex Care Management through the Primary Care Medical Home (PCMH), Wellness, Disease Management, Home Based Services, and Comprehensive Medication Review to best address ongoing health needs of the member.
- Supports the TCCI Program for all hospitalized CareFirst members, ensures the coordination and continuity of health care as patients transfer between different locations or levels of care
- Ensure Members have a Primary Care Provider (PCP) or Specialist appointment scheduled for a post-discharge appointment before the Member is discharged from the hospital.
- Conduct a clinical assessment of the Member and determine if the Member has ongoing care needs.
- Performs concurrent review for CareFirst members in accordance with the length of stay guidelines outlined for the Hospital Transition of Care Program.
- Consults with the Medical Directors for medical necessity determinations and appropriateness of care.
PRINCIPAL ACCOUNTABILITIES: Under the general direction of the Manager of Care Management, the incumbent’s accountabilities include, but are not limited to, the following:
(Note: Incumbent may be assigned to work onsite at one or more hospitals, or may be assigned to one or more hospitals to perform the essential job functions and engage with members, families and providers telephonically.)
Rapidly triages members into identified levels of care, as appropriate.
- Understands the Total Care and Cost Improvement (TCCI) Program concept and protocols and can advocate for the member.
- Contemporaneously, identifies members for program participation based on program guidelines, analytics and use of sound clinical judgment.
- Engages members to participate in appropriate TCCI programs, establishes relationship and follows up for ongoing coordination and assessment
- Assures member understanding of adequate support upon transition and knowledge of who to call if problem arise. Collaborates with facility staff as necessary to close gaps when identified.
Implements an effective TCCI program for members identified based on their appropriate level.
- Works with the hospital Admitting Office, Emergency Department, Registration and with CareFirst’s iCentric Portal to identify CareFirst Members who have been admitted
- Depending on whether the HTC is onsite or telephonic, meets/engages with identified members while hospitalized. Discusses and reviews the discharge plan, addresses member concerns, and proactively anticipates member needs at hospital discharge.
- Contacts hospital discharge planner, liaison, case manager or Local Care Coordinator/Behavioral Health Care Coordinator during the triaged member’s hospitalization. Discusses and reviews the discharge plan.
- Contacts identified CareFirst members post discharge and actively follow up to verify the transition plan and care connections.
- Coordinates necessary interventions.
- Communicates with PCMH when members are attributed to improve the care connections. Offers assistance to those members who do not have a primary care practitioner to select a provider for care coordination and improved outcomes through the CareFirst website.
- Primary role as coordinator/facilitator—proactively guiding members to the appropriate CareFirst programs and resources, to achieve program goals of reduced readmissions, cost-efficiency and quality outcomes.
- Ensures the transition of care from one setting to another for identified CareFirst members. Provides member centric interventions such as verifying appointments and coordinating medically necessary home health services.
- Offers assistance to members and providers for alternative settings of care.
Communicates and interacts professionally with physicians, other providers, and members.
- Builds and maintains a solid professional relationship with all targeted facilities (especially with hospitalists and Emergency Department physicians) and is proficient and knowledgeable about the Care Transition model. Communicates regularly on operational issues/concerns and barriers.
- Improves communication during transitions between providers, members and caregivers to assure smooth transitions.
- Provide timely and accurate communication of information as members move from one level of care to another.
- Registered nurse with current Maryland, Virginia or DC license and with no restrictions.
- 5 years of clinically related experience working in Care Management, Discharge Coordination, Home Health, Utilization Review or Disease Management.
- Basic understanding of the strategic and financial goals of a health care system or payor organization. Basic understanding of health plan or health insurance operations (e.g. networks, eligibility, benefits).
- Must be capable of working with minimal oversight, showing keen attention to detail and making critical decisions to ensure members have an effective plan of care that leads to optimal, cost-effective outcomes.
- Must have excellent analytical and problem-solving skills, excellent organizational, communication and coordination skills.
- Must have effective presentation, negotiation and influencing skills to interface with all levels of management and physician practices.
- Must be able to apply complex problem-solving abilities to achieve problem and process solutions.
- Excellent verbal and written communication skills, along with the telephonic and keyboarding skills necessary to assess, coordinate and document services for members.
- Knowledgeable of available community resources and programs.
- Must be able to effectively work in a fast- paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time. Must be able to meet established deadlines and handle customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
- Flexibility to work varied hours, and ability to travel by own means to a variety of locations to support business needs and to attend business meetings.
The incumbent is required to have had the vaccinations listed below and been appropriately screened (and cleared) for the items listed below. If the incumbent has not had them or been screened and cleared, they must do so upon acceptance of offer:
- TB screening (and repeat annually)
- MMR-V Immunity
- Influenza Vaccine (Seasonal)
The incumbent is required to complete the following training as assigned by Management, including, but not limited to:
- Infection control basics
- TB Awareness
- Bloodborne Pathogens (and repeat annually)
** Hospital Assignments are subject to change based on evolving business needs.
- Bachelor’s degree, preferably a BSN
- Working knowledge of managed care and health delivery systems
- 2+ years of managed care experience; e.g. case management/health coach, utilization management and/or auditing experience (may be included in the 5 years relevant clinical experience)
Potential Job Hazards:
The position could be located within an inpatient hospital facility.
- Incumbents are required to state their purpose upon arrival to the member’s room so there is no confusion as to their role vs. the role of the direct care hospital staff.
- Incumbents do not provide any form of direct patient care.
There is the potential for exposure to airborne illnesses, such as, but not limited to, tuberculosis, measles, mumps, rubella, varicella and influenza. The following administrative controls are in place to limit or minimize exposure potential:
- Incumbents do not enter any inpatient rooms, or hospital rooms designated with Respiratory precautions, or where any procedures are being done that produce respiratory droplets.
- Incumbents are required to remain at least 3 feet away from the inpatient member at all times.
There is the potential for exposure to Bloodborne Pathogens if not aware of surroundings at all times. The following administrative controls are in place to limit or minimize exposure potential:
- Incumbents do not touch patients;
- Incumbents must practice Universal Precautions at all times.
Department: Hospital Transition of Care
Equal Employment Opportunity
CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.
Hire Range Disclaimer
Actual salary will be based on relevant job experience and work history.
Where To Apply
Please visit our website to apply: www.carefirst.com/careers
Please apply before: 08/21/2019
Federal Disc/Physical Demand
Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.
The physical demands described here are representative of those that must be met by the incumbent to perform the essential duties and responsibilities of the position successfully. Requirements may be modified to accommodate individuals with disabilities.
- Must be able to provide face to face contact with inpatient member at assigned hospital facility.
- Must provide own transportation to drive to satellite CareFirst Blue Cross Blue Shield offices and/or assigned facility and to attend onsite any required meetings, trainings, or other assigned functions, at designated CareFirst office.
- Walking and standing is required. Lift weight up to 25 pounds on occasion.
- Hands are regularly used to write, type, key and handle or feel small controls and objects. Must be able to type and to speak on the telephone simultaneously.
- Must have the ability to communicate verbally effectively. Auditory ability to actively listen.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship