Concurrent Review Case Managers Needed

• Review and evaluate proposed services utilizing medical criteria and/or established policies and procedures. This includes review of submitted medical documentation and/or photographs.

• Determine the appropriate action with regard to the service being requested for approval, modification or denial, and refer to the Medical Director for review when necessary.

• Determine if the inpatient setting requested for surgery and/or medical care is appropriate.

• Initiate contacts with patient, family, and treating physicians as needed to obtain additional information or to introduce the role of case management.

• Analyze all requests with the objective of monitoring utilization of services, which includes medical appropriateness and identification of potentially high cost, complex cases for high-level case management intervention.

• For short-term cases, conduct a thorough and objective assessment of the member’s current status including physical, psychosocial, environmental, and gather all information pertinent to the case.

• Report cost analysis, quality of care and/or quality of life improvements as measured against the case management goals.

• Routinely assess member’s status and progress; if progress is static or regressive determine reason and proactively encourage appropriate referrals.

• Prepare and maintain appropriate documentation of patient care and progress within the care plan.

• Act as an advocate in the client’s best interest for necessary funding, treatment alternatives, timelines and coordination of care and frequent evaluations of progress and goals.

• Work collaboratively with staff members from various disciplines involved in patient care with an emphasis on interpreting and problem and solving complex cases.

• Document case notes and rationale for all decisions in the CCMS system.

• Other projects and duties as assigned.