Job Description

Especialista de Manejo de Cuidado US

Regular


Exempt

GENERAL DESCRIPTION:

Conducts nursing functions in performing care management processes, organizational determinations, and transitional care, including, health assessments, biopsychosocial needs assessment, and identification of barriers for policyholders with high-risk and high-cost medical conditions to develop a comprehensive and individualized care plan. Effectively determines and coordinates the services necessary to maintain policyholders' optimal level of health and facilitate access within and outside the coverage area as established in the policyholder's benefits and in the established timelines.

ESSENTIAL FUNCTIONS:

Evaluates the criteria for admission to Care Management Programs and Initiatives. Assesses the policyholder's condition to identify individual needs through a Health Risk Assessment. Prepares case summaries and interventions as requested. Regularly performs production of assigned cases and pre-certifications as established within the unit. Establishes a comprehensive and cost-effective Individualized Care Plan (ICP) with specific goals for each policyholder enrolled in the Care Management program, using their judgment and the clinical guidelines adopted by the Company. Proactively identifies problems and barriers affecting the policyholder's care, establishing achievable goals and short- or long-term case management strategies and interventions. Guides the patient and family during the phase of acceptance and adaptation to chronic medical conditions that may result from them and provides appropriate follow-up. Documents the progress of the policyholder's condition and all actions taken using the Enterprise Care Management Platform for documentation according to the policies and procedures established in the unit. Keeps effective communication about the policyholder's condition, treatment, and service coordination with the physician, the network, and the service provider within and outside the network. Evaluates their progress, guarantees integration into physical and mental health care, promotes self-care, and clarifies any situation related to the clinical services they receive. Performs Organizational Determination process in the established timeframe: clinical assessment, medical records analysis, benefits assessment, and availability of services to determine and coordinate services. Coordinates high-cost services with providers, medical offices, acute care facilities (Inpatient SNF and Rehabilitation), outpatient, dialysis centers, organ and tissue transplants, medical equipment, discharge planning, experimental studies, air ambulances, intravenous formulary medications, and specialty medications to generate changes in the health status and/or transitional care. Completes the appeals process within the period established with the Medical Advisor and the Grievance and Appeals unit. Evaluates the effectiveness of the policyholder's treatment, guarantees that authorized services were provided, and coordinates the services. Consults cases with Providers, the Medical Director, the Clinical Affairs management, and/or any other department when required to reevaluate the care plan, benefits, coordination of needed services, and/or utilization. Coordinates with other internal departments the necessary referrals to cover the clinical and social needs that apply to the policyholder. Actively participates in the Case Report and Clinical meetings to maintain compliance with the operational processes.


Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices. May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document.

MINIMUM QUALIFICATIONS:

Education and Experience:

Bachelor's degree in Nursing Sciences. At least three (3) years of experience in the direct care of patients with chronic health conditions. Some experience related to medical plans is preferred.

"Proven experience may be replaced by previously established requirements."

Certifications / Licenses:

A valid License and Registration of Nurse & Association Nursing Professionals of Puerto Rico is required.

Other:

Skills in handling computer systems, such as MS Office, among others.

Languages:

Spanish -

Advanced (comprehensive, writing and verbal)

English -

Advanced (comprehensive, writing and verbal)

"Somos un patrono con igualdad de oportunidad en el empleo y tomamos Accion Afirmativa para reclutar a Mujeres, Minorias, Veteranos Protegidos y Personas con Impedimento

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