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The Case Manager position is a full-time position that is responsible for conducting case management and quality activities in accordance to HI policies and procedures. The position responsibilities include the management of assigned cases to ensure costs are contained and quality of care is maintained as the patient accesses care and services in the continuum of care.
Case Management, according to the Case Management Society of America, is defined as; “a collaborative process of assessment, planning, facilitation for options and services to meet an individual's health needs through communicating available resources to promote quality cost-effective outcomes.” This service is recognized as an organized process designed to ensure the medical necessity and cost effectiveness of a proposed service. Case Management is designated to promote optimal recovery and rehabilitation by professional involvement in the rehabilitation process.
• Adheres to CM program goals and objectives in health care cost containment while maintaining a high quality of health care delivery system to meet the patient's individualized health care needs through adherence to program policies and procedures;
• Must become knowledgeable of NCQA and URAC requirements for Case Managers for CM accreditation;
• Performs telephonic case management activities, communicating with the multidisciplinary team in the timeframes required to meet program goals and objectives;
• Collects pertinent clinical information (including specific claims data when available), documenting findings using the HI case management information system program/hard copy charting;
• Summarizes and documents pertinent verbal discussions with the patient/patient's legally appointed representative, family, practitioner, other health care provider or the health purchaser staff, and/or any case conferences;
• Promotes alternative care and funding programs and researches available options to maximize health benefits and/or replace limited or excluded benefits;
• Promotes appropriateness of resources/placement when alternative level of care is required;
• Communicates directly with the patient/patient’s legally appointed representative, practitioner, other health care providers and team members when appropriate to gather all clinical information to determine the medical necessity of requested or needed health care services;
• Serves as a patient advocate when deemed applicable or as requested by the patient/patient's legally appointed representative; and,
• Initiates patient assessment.
• Assess the client's strengths, problems, prognosis, functional status, goals and need for specific services/resources, to establish short-term and long-term goals.
• Develops a plan, when indicated, through interdisciplinary collaboration which identifies options and goals.
• Identifies, procures and coordinates services and resources necessary to implement the individual's plan.
• Provides ongoing evaluation of the individual's progress, effectiveness of the rehabilitation plan, as well as, the efficacy and appropriateness of the services provided.
• Advocates on behalf of the individual to assure quality of care and attainment of appropriate goals.
• Promotes individual's self-advocacy skills to achieve maximum self-sufficiency.
• Communicates directly with the designated Medical Director or Physician Advisor or the Chief Medical Officer regarding all care/costs that:
o Are questionable;
o Do not meet criteria;
o Do not appear to meet medical necessity guidelines;
o Are experimental/investigational;
o Are beyond the dollar amount or scope allowed for the individual case manager;
o Are requested/required out-of-network;
o Are required over a prolonged period of time and an extended authorization for care is deemed appropriate for meeting a patient's individualized health care needs.
• Refers cases to HI legal and/or health purchaser’s legal staff where there is a threat of litigation and/or those patient's specified by the legal department for immediate referral;
• Recommends, coordinates or educates regarding alternate care options for patients, families, practitioners, providers or other members of the multidisciplinary health care team;
• Identifies any teaching required by the multidisciplinary health care team before the care/alternative level of care can be implemented;
• Identifies, in collaboration with the patient/patient's legally appointed representative, practitioners, other health care providers, health purchaser, the multidisciplinary team members and/or the HI Chief Medical Officer/Medical Director, the resources that will be required to meet/manage the patient's level of care/acuity of care requirements;
• Identifies and communicates to supervisor/director, all hospital ancillary providers, physician providers and physician offices, any concerns related to patient safety.;
• Develops, monitors and updates an individualized patient specific CM Plan in collaboration with the patient/patient's legally appointed representative, practitioners, and the multidisciplinary team members;
• Sets realistic, short and long-term goals for the patient as the CM Plan is developed and/or revised;
• Monitors the CM Plan at regular time intervals and/or at the time frequency dictated by the patient's level of acuity, making recommendations for change when opportunities are identified and/or as the patient's illness/health care needs improve or deteriorate;
• Negotiates discounts or reduced charges when an out-of-network provider is required to manage the level of care/acuity of the case at hand and/or in accordance to health purchaser contractual requirements;
• Maintains an active role in assuring continuity of care for patients through early identification and appropriate discharge planning by close and frequent collaboration with the hospital discharge planning/social worker staff;
• Closes and/or transitions stabilized cases after collaboration with CM Supervisor and/or Chief Medical Officer/Medical Director
• Readily available to non-clinical staff to answer questions and ensure that non-clinical staff is performing within the scope of the non-clinical role
Cc Customer Services-Internal
• Creates and supports a positive and supportive working environment;
• Identifies and resolves potential personnel/peer problems and issues proactively;
• Communicates to CM Supervisor and/or Director UM/CM all problems, issues and/or concerns as they arise.
• A bachelors (or higher) degree in a health-related field preferred.
• Case Management certification within three years of employment required.
• Current, unrestricted RN licensure, or LCSW, LMHC, or LMFT licensure required.
• Three (3) years clinical practice experience required.
• Practice case management within the scope of their licensure (based on the standards of the discipline)
Work Experience Requirements:
• Two-three years clinical experience in case management or acute hospital discharge planning preferred;
• Three years full-time direct clinical or critical care to patients in a medical/surgical or behavioral health setting; or
• Three years of experience in applying healthcare criteria or a behavioral health set of criteria
Available: Tuesday – Saturday 3:30pm 12:00am