Patient Care Resource Manager

• Job Description Position Summary : Serves as a service team member who coordinates and evaluates health care delivery for 50,000+ university health plan members and affiliated groups by collaborating with the member's health care team (comprised of the patient, family, doctor, health care facilities and other related entities outside the health plan) to determine appropriateness of care from diagnosis to outcome;
• responsible for carrying out the management of specific, individual medical episodes identified through utilization review, and quality assurance functions;
• uses predictive tools to promote timely preventive personalized and participatory services; helps members identify opportunities for improvement and refers to resources to optimize their efforts;
• assists in development and implementation of medical guidelines and departmental policies and procedures; works to assure appropriate medical benefit application and claims payments;

requires successful completion of a background check. Minimum Education Required Bachelor's Level Degree or equivalent combination of education and experience Required Qualifications Bachelor's Degree or equivalent education / experience Major-Nursing.

Experience in health plan case management; experience in disease case management and wellness programs; experience in acute care setting for patients with complex, chronic and multi-system conditions desired.

100%

The Patient Care Resource Manager serves as a member of the service team responsible for executing and promoting care management programs for university health plan members and affiliated groups by collaborating with the members and their health care team.

The Patient Care Resource Manager reports to the Manager of Care Management and works collaboratively with directors, managers, and clinicians to ensure delivery of differentiated, affordable, high quality and personalized health care services in an accessible, patient-friendly focused atmosphere.

The Patient Care Resource Manager guides and supports new PCRM team members.

• The Patient Care Resource Manager u tilizes expanded conceptual and practical disease state knowledge to manage a caseload of moderate to high-risk patients with acute / chronic conditions and complex medical / psychosocial needs;
• applies motivational interviewing techniques for assisting members to move through the stages of behavioral change to reduce risk of disease processes;
• coaches members in identifying opportunities for improvement and refers to resources to optimize their efforts ; exercises clinical process, critical thinking, and problem solving skills to collaborate with members, providers, practice managers, and internal clinicians to solve benefit issues in an accurate and timely manner and ensure members receive high level care throughout the care continuum;
• advocates for members and families by helping them to coordinate care and navigate resources throughout the healthcare system;
• explains complex information to patients, family members, and other clinicians in straightforward situations; effectively and efficiently documents treatment plans and outcomes;
• maintains expanded clinical knowledge and patient education skills in diabetes, heart failure, coronary artery disease, asthma, and COPD;

works independently with moderate guidance.

• The Patient Care Resource Manager recommends program / policy improvements based on current guidelines and interactions with members and providers ;
• works to assure appropriate medical / pharmacy benefit application and claim payments; performs self-audits and quality monitoring to improve performance;

assists with the development and implementation of clinical guidelines and departmental policies and procedures.