Provides Case Management services to a specific clientele.
Systematically identify and addresses fragmentation of care, and fill gaps in are using proactive initiatives.
Assesses medical records for appropriateness, level of care provided and criteria determination.
Identifies appropriate care for patients by evaluating high-risk cases, intensity and complexity of services, health care costs and non-compliance issues.
Coordinates care between multiple providers.
Develops care plans in coordination with providers, patients, families as appropriate and assess the effectiveness.
Organizes and schedules training for all new Case Management employees.
May conduct periodic quality assurance audits for accuracy and quality associated with training.
May monitor and oversee workflow function in case management.
Coordination of Care
Contacts members of the medical team to discuss the patient's course of progress and needs.
Arranges for all services required; coordinates services with the health care team to eliminate duplication of service and conserve benefit dollars.
Contacts/visits family to check understanding of the patient's diagnosis, prognosis and ability to provide caregiver support.
Checks home for safety factors and structural barriers, arranges for modifications
Reevaluates equipment, supplies, and services.
Identifies problems, anticipates complications and acts to avoid them; provides health instruction to the patient/family; refers the patient back to the physician or other health care team members as needed.
Identifies plateaus, improvements, regressions and depressions; counsels accordingly and recommends help.
Makes personal visits/contacts the physician to clarify diagnosis, prognosis, therapies, activities of daily living, etc.
Provides authorizations for any modalities of treatment recommended; investigates and suggests alternative treatments when appropriate.
Assists with getting information and forms for living wills, health care proxy, DNR order, etc.
Shares pertinent information about the patient with physician to achieve the best outcome.
Documents case summary based on information received and communicates with the beneficiary and involved providers.
Conducts personal visits to the patient's home/hospital as needed.
Facilitates transfer of beneficiary throughout the different regions and within the region by collaborating with the military liaison to transition the beneficiary with minimal disruption of their health care services.
Coordinates the basic benefit and identifies and submits benefit modifications as appropriate or submits a request to TMA for benefit exceptions/special programs.
Coordination of Financial Services
Assesses the benefit plan for coverage and limitations.
Negotiates for cost-effective rates for provider services, which includes:
Contacts multiple providers for a rate comparison of specialty items and identification of the most cost-effective approach.
Researches and identifies appropriate equipment that meets the beneficiary's needs and pursues contracts with these providers.
Suggests medically appropriate alternatives to accomplish treatment plan goals more cost effectively.
Counsels the patient/family on budgeting and notifying creditors.
Identifies financial distress and refers patient/family to appropriate community resources.
Helps patient /family sort and prioritize bills.
Acts as liaison among secondary insurance payers.
Aids with Behavioral/Motivational Activities
Explores patient's feelings about his/her injury or illness; helps with associated trauma and frustration.
Monitors family's feelings about the patient's illness and observes the family's ability to manage new emotional stress.
Offers information about patient's condition.
Enlists qualified counselor to assist with problems arising from the injury or illness.
Post Discharge Follow-up
Contacts patient within 48 hours of discharge assuring proper support and services are in place to make a full recovery (i.e., equipment, home health, other services, transportation, etc.).
Ensures patient effectively navigates the health care system.
Evaluates Referrals and Pre-admission/Admission Counseling
Assesses patient's condition, understanding of their injury and their ability to follow the treatment plan.
Contacts patients with upcoming medical or surgical admissions and discusses what they may expect before, during and after the admission.
Contacts members of the medical team to discuss the patient's course of progress and needs utilizing available discharge information (if there was a hospitalization) and the initial needs assessment.
Works with physicians and hospitals to enforce treatment plans and orders, ensures patients receive specialty care and tests when ordered.