Anthem, Inc. Managed Care Coordinator-Clinician (Non RN) in Norfolk, Virginia
SHIFT: Day Job
Your Talent. Our Vision. At Anthem, Inc., it’s a powerful combination, and the foundation upon which we’re creating greater access to care for our members, greater value for our customers, and greater health for our communities. Join us and together we will drive the future of health care.
This is an exceptional opportunity to do innovative work that means more to you and those we serve at one of America's leading health care companies and a Fortune Top 50 Company.
Managed Care Coordinator-Clinician (Non RN)
Location : Virginia Remote / Virtual (must live in the state of Virginia)
Hours: Monday through Friday, 8am to 5pm
Working under the direction/supervision of an RN, with overall responsibility for the member's case, as required by applicable state law and contract, contributes to the care coordination process by performing activities within the scope of licensure including, for example, assisting the responsible RN with telephonic or face-to-face assessments for the identification, evaluation, coordination and management of member's needs, including physical health, behavioral health, social services and community services and supports.
Assists responsible RN in identifying members for high risk complications.
Obtains clinical data as directed by the responsible RN.
Assists the responsible RN in identifying members that would benefit from an alternative level of care or other waiver programs.
Provides all information collected to the responsible RN, who verifies and interprets the information, conducts additional assessments, as necessary, and develops, monitors, evaluates, and revises the member's care plan to meet the member's needs.
Participates in coordinating care for members with chronic illnesses, co-morbidities, and/or disabilities as directed by responsible RN, and in conjunction with the RN, member and the health care team, to ensure cost effective and efficient utilization of health benefits.
Decision making skills will be based upon the current needs of the member and require an understanding of disease processes and terminology and the application of clinical guidelines but do not require nursing judgment.
Identifying via the Daily Census, Collective Medical and the Transition of Care email box any members who are on the HU list and any members who have been admitted for more than 48 hours to the hospital.
Participating in the discharge process to assure a safe, timely discharge from in-patient settings to appropriate community settings with the right supports at the right time to reduce lengths of stay, readmissions and promote the best health of the member.
Outreaching to any identified members and their care team, the Anthem UM nurse, and the hospital discharge planner.
Assessing members needs by identifying and planning for gaps in care.
Identifying and coordinating in-network resources to meet the needs of the member upon discharge and assuring initiation of these services are in a timely manner meeting quality standards.
Developing regional resource lists to include in-network providers and DME outpatient resources.
Obtaining a copy of the hospitals discharge plan of care and assist with assuring all providers are in network, appointments and transportation are scheduled, and member understands and agrees with the plan.
Maintaining a caseload of members identified as high utilizers of ED services and manage these members aggressively to reduce unnecessary ED usage. TCC’s will outreach to these members and establish positive and trusting relationships identifying clinical and SDOH drivers that are causing ED visits. Coordinate a team approach that addresses these drivers/gaps in care that will help meet the needs of the member in the community versus the ED except for true emergencies. This includes working with the ARTS and BH teams as needed.
Following up on members who have returned home from the hospital within 24 hours of discharge. Assuring that resources are in place and meeting needs, appointments are scheduled and transportation arranged.
Communication with the members CCC+ CC including weekly updates on the member’s status and status post discharge prior to closing the case.
Maintaining the spreadsheets to track members and their discharge plans, completing all documentation in a timely manner that meets NCQI guidelines.
Identifying needs for LTSS services, assisting with the coordination of these supports including facilitating the completion of the UAI and making timely referrals to the LTSS team. Entering all data on these members on to the LTSS tracker.
Identifying members, who require SNF stays early in the hospital discharge process, assisting with the location of an in-network provider, coordinating with the SNF provider relations associate to procure a single case agreements to reduce length of stay in an in-patient setting. Assist with the transition and follow member while in the facility. Assist with discharge planning from the SNF to home including setting up EDCD services or home health. Keeping any specialty facilities such as Group Homes or Sponsored Residential providers apprised of plans, needs and services available to assist them in meeting the member’s needs. Assuring that a UAI’s is completed early in admission process to allow for the earliest safe transition to LTSS as needed.
I/DD members: Work with members and their support teams to determine next level of care needed early in the admission process. Determine if the GH, SR or parent can meet the expected discharge needs of the member. Facilitating communication between all parties involved in the discharge including the CSB Support Coordinator, the residential provider, caregivers and hospital discharge planner to coordinate services from both the DD waiver and CCC+ program to facilitate a smooth transition.
Requires an LPN/LVN, LSW, LCSW, or LMSW or license other than RN in accordance with applicable state law; Nursing Diploma or AS in Nursing or a related field; 2 years of experience in working with individuals with chronic illnesses, co-morbidities, and/or disabilities in a Service Coordinator or similar role; or any combination of education and experience, which would provide an equivalent background.
Current, unrestricted LPN/LVN, LSW, LCSW, LMSW or license other than RN (as allowed by state law) in applicable state(s) required.
Masters in Health/Nursing preferred.
At least two years providing Care Coordination/Case Management for members in the CCC+ program or other comparable position preferred
May require state-specified certification based on state law and/or contract.
Travel may be required.
An ideal candidate will live in the Central Region of Virginia
Internet speed for all associates must meet the minimum speed requirement.
Approved: Cable. Some examples: AT&T, Charter, Comcast, Spectrum, Verizon FIOS
Not approved: Satellite, dial up, aircards. Some examples: Direct TV, Exede, Hughesnet. MIFI or "hot spots" are not permitted for regular home use and are not intended to be substitutes for true internet provider services.
What We Offer
We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.
Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and has been named a 2019 Best Employers for Diversity by Forbes. To learn more about our company and apply, please visit us at careers.antheminc.com. An Equal Opportunity Employer/Disability/Veteran. Anthem promotes the delivery of services in a culturally competent manner and considers cultural competency when evaluating applicants for all Anthem positions.