Applicants must reside in the Northern/ Central Virginia area and be willing and able to travel 25-40% of the time in the assigned region. Mileage is reimbursed per our company expense reimbursement policy. This is a full-time remote teleworker position in Northern/ Central Virginia supporting the Early Intervention/ Children and Youth with Special Health Care Needs team.
Qualified candidates must reside in the Northern Region of Virginia in Culpeper, Rappahannock, Fauquier, Manassas, Falls Church, Arlington, Alexandra, Fairfax City, Fairfax, Prince William, Fredericksburg, Stafford, King George and surrounding areas.
Job description
Utilizes skills to coordinate, document and communicate all aspects of the utilization/benefit management program.
-Applies critical thinking and knowledge in clinically appropriate treatment, evidence based care and medical necessity criteria for members by providing care coordination, support and education for members through the use of care management tools and resources.
Evaluation of Members; Through the use of care management tools and information/data review, conducts comprehensive evaluation of referred member’s needs/eligibility and recommends an approach to case resolution and/or meeting needs by evaluating member’s benefit plan and available internal and external programs/services.
-Identifies high risk factors and service needs that may impact member outcomes and care planning components with appropriate referrals.
-Coordinates and implements assigned care plan activities and monitors care plan progress.
Enhancement of Medical Appropriateness and Quality of Care;
-Uses a holistic approach to overcome barriers to meet goals and objectives; presents cases at case conferences to obtain multidisciplinary review in order to achieve optimal outcomes.
Identifies and escalates quality of care issues through established channels.
-Utilizes negotiation skills to secure appropriate options and services necessary to meet the member’s benefits and/or healthcare needs.
-Utilizes influencing/ motivational interviewing skills to ensure maximum member engagement and promote lifestyle/behavior changes to achieve optimum level of health.
-Provides coaching, information and support to empower the member to make ongoing independent medical and/or healthy lifestyle choices.
-Helps member actively and knowledgably participate with their provider in healthcare decision-making. Monitoring, Evaluation, and Documentation of Care;
-Utilizes case management processes in compliance with regulatory and accreditation guidelines and company policies and procedures.
Required Qualifications
- Must be willing to travel up to 25-50% of the time
- Must reside in one of the following counties: Stafford, Fredericksburg, King George, Spotsylvania, Caroline, Essex, Westmoreland, Northumberland, Richmond, King and Queen, Hanover, Culpeper, Fauquier, Loudon, Manassas Park, Falls Church, Arlington, Alexandra, Fairfax City, Fairfax, Manassas, Prince William.
- 2+ years of case management experience working with people who have been designated as having a serious mental illness (SMI) and working with people who are elderly or have a physical disability.
Preferred Qualifications
- Computer proficient with Microsoft Outlook/Word and Windows
- Experience collaborating with medical professionals
- Critical areas to succeed - organization, collaboration and time management
Education
Candidates must have earned a 4-year bachelor’s degree in social work, psychology, special education or counseling.
