Oncology Case Manager: AvMed Health Plans

SCOPE OF POSITION:

The Oncology Case Manager will serve as a liaison between the attending physician, the Member, and the healthcare provider. Through assessment, monitoring and recommendations by the team Members, the Oncology Case Manager will work within the guidelines of medical benefits to assist in finding the most optimal solution for the Member’s oncology needs. The Oncology Case Manager will be responsible for working with the physician, AvMed Pre-Authorization, AvMed Pharmacy, Disease or other Case Management programs, Concurrent Review staff, and the Member and/or family to promote quality care that is delivered in the appropriate setting. The Oncology Case Manager will work with the Medical Director to assess, plan, implement, coordinate, monitor and evaluate services and outcomes to maximize the health of the Member.

ESSENTIAL JOB FUNCTIONS:

Identify Member’s at risk for adverse outcomes for oncology case management and/or other care management programs. Assess Member’s goals as well as their biophysical, psychosocial, environmental, and discharge planning needs. Work with physicians, providers, to develop a Member’s plan of care. Maintain records documenting the plan of care and contacts with all members of the team. Assess, develop, implement, and monitor a comprehensive plan of care with the PCP, providers, and Members/families, and other care management programs, as appropriate. Obtain covered services and serve as an advocate on behalf of the Member and families for limited resources based on the member’s “Certificate of Coverage”. Act as liaison to post-hospital care providers and community resources (i.e., transportation, Meals-on-Wheels). Maintain records accurately documenting the plan of care and contacts with the PCP, providers and Members, and entering all cases into AMISYS, document MOR and enter into other designated systems. Communicate regularly with Utilization Management staff and family to assist with discharge planning and offer non-acute care options for inpatient Members. Plan team conferences and family meetings, as necessary, to discuss care options with the physician and providers. Determine levels of acuity for all referred Members. Act as liaison between the PCP and contracted home health providers to oversee medically appropriate authorization of services. When appropriate, perform concurrent telephone review and/or home visits to verify the services being provided are consistent with the medical orders. Assess the appropriateness of the level of care; diagnostic testing and clinical procedures; quality and clinical risk issues; and documentation of medical record completeness. Function as a liaison within the Medical Department and with members to promote the appropriate utilization of health care resources. Work with the PCP to terminate services when homecare or outpatient services are no longer medically necessary. Notify the Member, family, and agencies when services are terminated. Function as liaison to promote an effective working relationship with providers. Providers may include the PCP, specialty physicians, SNF's, home care or DME vendors, infusion companies, or any contracted health care agency. The OCC will serve as an informed resource on AvMed policies and benefits to all providers and proactively identify problems with possible solutions. Refer Members to community resource or government programs when needed (e.g., Medicaid, pharmacy programs). Function as a liaison within the Medical Department and with Members to promote the appropriate utilization of health care resources. Document outcomes for oncology care management interventions. Educate AvMed departments about the role of the Oncology Case Coordinator to determine appropriate identification of potential cases from provider relations, Member relations, and claims. Maintain open communications with the concurrent review, quality assurance and pre-auth staff to determine appropriate cases are identified. Demonstrates effective communication methods and skills, using lines of authority appropriately. Practices capable and effective problem identification and resolution skills as a method of sound decision making. Identify potential quality of care and/or risk issues and report to appropriate department. Completes quarterly review of readmits, high utilizers and high risk Members, as directed.

AvMed Health Plans is a Drug/Tobacco-Free Work Place, EOE.