As an integral member Population Health Management Initiative the Integrated Care Manager is responsible for establishing implementing monitoring and evaluating high quality cost effective care plans for a designated group of patients in the ambulatory based setting.
Consistent with a Patient Centered Medical Home (PCMH) team based care model the Integrated Care Manager (ICM) may be embedded in select NWPHO affiliated primary care practice(s) and will collaborate with the primary care physicians and other members of the patients care team to plan and implement optimal and efficient care plans and design approaches to care for a defined population of patients managing their care across the continuum.
This position requires a broad knowledge of clinical care available health services across the continuum of care insurance benefit design and reimbursement methods care integration systems and management and experience in acute care or community case management.
1 Incorporates knowledge of case management standards payer rules and coverage and utilization management principles to implement high quality cost effective care plans.
2 Provides information and education as necessary to other members of the care team regarding insurance benefit design and coverage health care options and available community resources.
3 Influences appropriate utilization of health care resources by coordinating patient care across the continuum encouraging involvement in disease and case management programs and conducting followup care prior to and post interaction with the broader health care system including acute care admissions emergency department visits specialist visits and subacute care settings.
4 Using medical management criteria and/or other Partners approved diagnostic screening criteria collaborates with hospital and/or subacute staff to understand the appropriateness of hospital and/or subacute admissions length of stay and readmissions.
5)Authorization and coordination of services which may include; determining appropriate level of care management of patients health benefits authorization for approved services in compliance with federal and state standards and in compliance with health plan guidelines as appropriate as well as referrals to community agencies.
1. RN graduate of an accredited school of nursing and currently licensed to practice in Massachusetts.
2. Minimum of 5 years experience in hospital health plan or community case management or utilization management role.
1. Preferred qualifications include:
a. BSN BS or BA
b. Certification in case management (CCM) (ACM) or other applicable professional certification
c. Previous experience working in a post acute setting such as LTAC acute rehabilitation skilled nursing facility or homecare.
d. Previous experience working in an ambulatory setting such as a health center or physicians practice.
e. Managed care or health care reimbursement experience with a working knowledge of nationally accepted utilization review criteria (InterQual Milliman).
2. Evidence of continued education and professional development.
NWH - INTEGRATED CARE MANAGER - NWPHO iCMP
