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General Purpose of Job:

The service coordination program supports maximizing the member’s health, wellbeing, and independence.  The RN will focus on person-centered care planning and will assess all the member’s services and support needs, all assure timely community-based Long Term Services and Supports (LTSS) to prevent, delay, or reduce the progression of chronic conditions and the need for institutionalization and to maintain the member safely in the community.  Service coordination is a collaborative practice that assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet the member’s health and human service’s needs.  It is characterized by advocacy, communication and resource management and promotes quality and cost-effective interventions and outcomes.  The service coordinator facilitates clinically appropriate and fiscally responsible patient care through communication with the physicians involved in the members care, family, care giver, and all other members of the health care team.  The service coordination process is holistic in its coverage of the member’s situation and addresses medical, physical, behavioral, emotional, financial, psychosocial, and other needs, as well as that as the support system.  These nurses will also work with the Health Homes and high volume primary care providers to assist with coordination of STAR Kids member’s needs.  This Service Coordinator will be responsible for all Level I and Level II members.  The Service Coordinator is responsible for the acute care authorizations, concurrent review, and collaborating with each member’s Service Coordination Integration Pod (SCIP) for discharge planning, and assists with disease management for the level 1, 2 and 3 members.

The Service Coordinator is responsible for the coordination and efficient utilization of health care resources for the provision of quality care for all patients throughout the continuum of care. The LTSS Case Manager:

facilitates clinically appropriate and fiscally responsible patient care through communication with the providers and health plan medical directors, and all other members of the health care and health plan team, assesses and identifies the patient’s clinical findings and determines, in conjunction with the Physician Advisor/Health Plan Administration, established benefits, protocols, pathways, and evidence based medicine tools, the health care services and level of care appropriate for the member, reviews services either prospectively, concurrently, or retrospectively, communicates with providers of care/services to ensure appropriate levels of care and coordination of LTSS for applicable members, and

Essential Duties and Responsibilities:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.  The requirements listed below are representative of the knowledge, skill, and/or ability required.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. This job description is not intended to be all-inclusive; employees will perform other reasonably related business duties as assigned by Health Plan leadership, as required.

Knowledge, Skills and Abilities:

Knowledge in Texas Medicaid criteria/guidelines preferred. Knowledge about managed care contracts/guidelines preferred. Knowledge of programs and services required to support the health and medical needs of disabled children preferred. Knowledge of various reimbursement mechanisms, including third party requirements preferred. Knowledge of various utilization criteria sets (e.g. InterQual) preferred. Microsoft Office skills preferred. Maintains utmost level of confidentiality at all times. Maintains compliance with regulatory agencies that conduct intermittent reviews and audits to ensure contractual and regulatory compliance with Federal, State entities as well URAC. Implements and adheres to Health System and Health Plan policies and procedures for members with special health care needs (STAR Kids). Demonstrates business practices and personal actions that are ethical and adhere to Corporate Compliance and integrity guidelines. Behavioral Health experience preferred.

Responsibilities:

Function in an advisory role to the Medical Directors and Medical Management Committee in the following areas:

Provide evaluation of and assist in the development of quality patient care services offered by DCHP;

Assist in the establishment of patient care and professional staff policies and procedures of DCHP; and

Participate in long-range planning of services and/or programs offered by DCHP.

This position shall be responsible for the following aspects of the program:

Works inside the health home and assists the practice in coordinating, integrating, collaborating the necessary services and supports that the STAR Kids require.

Work with high volume primary care providers in coordinating, integrating and collaborating the necessary services and supports that the STAR Kids require.

Participates in timely completion of assessment activities meeting State contractual requirements for STAR Kids.

Administer the STAR Kids assessments at the time of enrollment, annually, a change of condition, and when requested to assess the member’s overall needs across all disciplines and utilize the assessment to drive the individualized service plan (ISP) that will support service coordination.

Provide the member with initial and ongoing assistance identifying, selecting, obtaining, coordinating, and using services and supports to enhance the member’s wellbeing, independence, integration into the community, and potential for supportive employment.

Coordinates care and efficient utilization of health care resources for patients identified in the STAR Kids program through communication with other members of the health care team, including physicians, social workers, nurses, and other multidisciplinary team members as appropriate to obtain optimal outcomes for members.  Develops ISP.

Coordinates the member’s intake process by reviewing the physician orders, confirming eligibility, benefits, and coordinating the completion of all associated paperwork while orienting members and family to managed care service coordination.

Complete documentation about a member’s service coordination plan of care, progress toward meeting care goals, outcomes, case reports, etc. Review assessment results with the member and authorize services as indicated by the assessment,  member goals and preferences, and caregiver or provider input. Ensure thorough knowledge of the STAR Kids contract and meet all Service Coordination contract requirements. negotiates with vendors when necessary for services/equipment Authorizes LTSS services and provides member with ongoing assistance for services and supports. Coordinates with all other STAR Kids waiver programs. Enrolls member in disease management and monitors and documents progress. Ensure appropriate referrals to agencies and assistance programs are completed. Utilizes processes to include physical, needs, and psychosocial assessment, planning, implementation, coordination, monitoring and evaluation. Communicates with management regarding status of current workload and turn-around time discrepancies as necessary.  Must obtain approval from manager or designee to any redistribution of workload. Must be knowledgeable about managed care Medicare/Medicaid criteria/guidelines Must be knowledgeable of data-driven decision making tools and their use. Must have a working knowledge of various reimbursement mechanisms including third party requirements and Medicare. Produce status reports on a regular basis to track members in STAR Kids. Participates in health plan’s performance improvement activities. Participates in health plan committees as appropriate and on request. Accepts other assignments from management as requested and complies with basic management principals of delegation. This position shall also be responsible to perform other such professional services as may be requested by DCHP from time to time. Participate in timely completion of preauthorization activities for outpatient and inpatient services. Collaborates with the service coordinators for discharge planning for all STAR Kids members. Identify members with special health needs for possible disease management programs available within the plan. Ensure that initial, as well as continued stay case management assessments include the use of approved criteria for inpatient and observation cases. Seeks clarification from staff, ancillary departments and attending physicians when necessary. Collaborate with hospital case management to assure that impediments to safe discharge are recognized immediately and corrective action strategies are developed to ensure patient safety and maximize positive outcomes for the member and the organization. Complete concurrent and/or retrospective review for condition specific criteria and appropriateness of hospital treatment, using plan-approved evidence based criteria.

Education and/or Experience:

This position can be filled as an RN, Nurse Practitioner, or Physician’s Assistant.

• Bachelor of Science in Nursing (BSN) degree from four-year college or university or equivalent combination of education and experience in managed care, STAR+Plus, children with special health care needs, or Long Term Supports and Services (LTSS) for individual enrolled in various waiver programs through the Department of Aging and Disability Services (DADS) preferred.
• Certified Case Manager (CCM) certification preferred.
• Minimum of 3 years of clinical experience as a Registered Nurse with one year of experience as a case manager or managed care case/utilization management experience preferred.
• Minimum of three (3) years prior management experience in health services within a managed care organization preferred.
• Must have an in-depth knowledge of the State of Texas’ managed care and managed Medicaid process preferred.
• Previous experience with the State of Texas STAR+PLUS program or similar programs dealing with SSI and disabled children preferred.
• Knowledge of Medicare preferred.
• MNLOC/RUG certification preferred.

Licenses, Certifications, Registrations:

• Current, active, and unrestricted RN, NP, or PA  licensure in the State of Texas
• Certified Case Manager (CCM) designation preferred.
• Current Texas driver’s license and insurance maintained throughout the term of employment.