Pediatric RN Transitional Case Manager - Children's Medical Services / Foster Care Program
WellcareFull time Full day
Headquartered in Tampa, Fla., WellCare Health Plans, Inc. (NYSE: WCG) focuses primarily on providing government-sponsored managed care services to families, children, seniors and individuals with complex medical needs primarily through Medicaid, Medicare Advantage and Medicare Prescription Drug Plans, as well as individuals in the Health Insurance Marketplace. WellCare serves approximately 5.5 million members nationwide as of September 30, 2018. WellCare is a Fortune 500 company that employs nearly 12,000 associates across the country and was ranked a "World's Most Admired Company" in 2018 by Fortune magazine. For more information about WellCare, please visit the company's website at www.wellcare.com. EOE: All qualified applicants shall receive consideration for employment without regard to race, color, religion, creed, age, sex, pregnancy, veteran status, marital status, sexual orientation, gender identity or expression, national origin, ancestry, disability, genetic information, childbirth or related medical condition or other legally protected basis protected by applicable federal or state law except where a bona fide occupational qualification applies. Comprehensive Health Management, Inc. is an equal opportunity employer, M/F/D/V/SO.
Works in collaboration with a member's primary care manager (CM) to ensure safe and appropriate transition between levels of care, including working as a part of the interdisciplinary care team in the development and execution of a person-centered transition plan. Coordinates with support staff, (e.g., Housing Outreach Specialist, Education Specialist, DME Specialist, and Community Advocates) and services required for a safe transition. Along with the primary CM, collaborates with family/caregivers to identify and ensure member and/or caregiver needs are met and services are in place to support a successfully achieving transition goals.
Establishes and maintains best practices reflecting regional variations affecting guardianship, successful transitions and/or HCBS capacity, including establishing relationships with key facilities, providers, and home and community based (HCBS) resources to assist in transitions. Assists with identifying resources with specialized capabilities when members with complex needs transition to the community, residential facility or group home. Identifies members residing in nursing facilities or other institutions who are candidates for transitioning back to the community. Assists in reviewing and analyzing data related to rebalancing and developing action plans to meet rebalancing goals. Partners with internal staff and external stakeholders to develop innovative solutions to expanding HCBS capacity based on Regional nuances and State/Federal regulations.
Florida Children's Medical Services (CMS) Plan-Specific Job Summary:
The CMS Transitional Care Manager helps support complex transitions to adulthood, provide training, guidance and support to other care managers. The Transitional Care Manager monitors the effectiveness of transition planning and works to ensure smooth transition by mitigating disruption in services when enrollees' eligibility changes from Medicaid to CHIP, or visa versa. The Transitional Care Manager works with the member and their family, beginning at age 12 years old, on the development and implementation of a transition plan that helps support them as they transition into adulthood. Transition planning includes partnering and collaborating with the member and their family, pediatric providers, and adult providers. Planning also includes but is not limited to, identification and establishment of specific transition plan milestones and member and family readiness assessments.
DEPARTMENT: PHS- FL CMS
REPORTS TO: Sr. Director, Field Care Management
- Responsible for identifying members with an opportunity to re-enter the community and exercises independent judgment in the final determination of the appropriateness of the member to transition out of the facility.
- Conducts research, including reviewing reports, medical records, service authorizations, claims history, case notes, caregiver needs etc., and employs clinical expertise to determine member needs for safe transitions to the community and supports the member’s residential choice in the least restrictive setting.
- Collaborates with the primary Care Manager to conduct in person or telephonic outreach to members, providers and community organizations to support Case Management and/or Quality Improvement, regulatory and contractual metrics and requirements related to community transitions.
- Positively collaborates with field health services staff as a part of the interdisciplinary care team to lead transition activities in conjunction with the primary care manager.
- Maintains accurate records of activities in the care management platform.
- Maintains HIPAA standards and ensures confidentiality of protected health information. Reports critical incidents, including incidents of abuse, neglect, and exploitation, and information regarding quality of care issues.
- Serves as a liaison in corresponding and communicating with providers, vendors and other identified stakeholders to influence rebalancing metrics.
- Ensures compliance with all state and federal regulations and guidelines.
- Acts as subject matter expert in regards to regional best practices, contract requirements, and department processes that support successful community transitions.
- Identifies strategic community providers and stakeholders and establishes positive partnerships and innovative approaches to create/expand community capacity to positively influence rebalancing.
- Determines relevant data points to analyze, and performs analysis to proactively identify areas of opportunity for rebalancing and develops action plans to meet goals.
- Represents supervisor and/or management team in assigned meetings, special projects, and/or community-facing events.
- Acts as lead to complete specific contract required functions to ensure compliance, communicating with specific state partners and providers.
- Performs other duties as assigned.
Additional Position Responsibilities/CMS:
Works with member and their family on the development and implementation of at transition plan that helps support the member as they transition into adulthood, to include: educational and vocational supports, housing, income and guardianship.
Will travel to inpatient bedside, member's home, provider's office, hospitals, etc as required with dependable car. May spend up to 70% of time traveling with exposure to inclement weather and normal road hazards.
- Required an Associate's Degree in Health Services or Nursing
- Preferred a Bachelor's Degree in Health Services or Nursing
- Required 3 years of experience in experience in working with nursing facility eligible individuals with chronic illnesses, co-morbidities, and/or disabilities in a Service Coordinator, Case Management, or similar role; or any combination of education and experience, which would provide an equivalent background.
- Required associates supporting Florida's Children’s Medical Services (CMS) must have a minimum of two (2) years’ experience in Pediatrics clinical care, and experience in managing care for including high-risk groups, such as children with SED (severe emotional disturbance), with co-occurring major mental disorders and SUD (substance use disorder), who are involved in multiple service systems (education, justice, medical, welfare, and child welfare); Children with medical fragility/complex medical conditions requiring significant medical or technological health supports.
- Intermediate ability to work independently
- Intermediate ability to multi-task
- Intermediate ability to work in a fast paced environment with changing priorities
- Intermediate demonstrated interpersonal/verbal communication skills
- Intermediate ability to effectively present information and respond to questions from families, members, and providers
- Intermediate knowledge of healthcare delivery
- Intermediate ability to represent the company with external constituents
- Intermediate ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
- Intermediate knowledge of community, state and federal laws and resources
- Intermediate demonstrated problem solving skills
- Intermediate demonstrated customer service skills
Licenses and Certifications:
A license in one of the following is required:
- Required Licensed Registered Nurse (RN)
- Required intermediate Healthcare Management Systems (Generic)
- Required intermediate Microsoft Outlook
- Required intermediate Microsoft Excel
- Required intermediate Microsoft Word
- Preferred intermediate knowledge of data entry, documentation and report generation in any clinical system
- Preferred Bilingual English/Spanish
All your information will be kept confidential according to EEO guidelines.