Case Manager (Nurse) at Avon HMO

Objectives of the Role

• Oversee, identify, accredit, contract, train, and manage the primary care providers and medical specialists who provide services to the enrollees (members) on the company’s health insurance plans.
• Develops, coordinates, implements, and evaluates case management services to health plan enrollees/members and health care providers that contract with the HMO.
• Collaborates with other staff in evaluating the placement of members in proper primary care locations, developing and adapting forms and information systems, and mediating difficult member and provider situations.
• Oversight of timely medical management, utilization management, and discharge management interventions to meet clinical targets, assure the provision of a continuum of care to enrollees

Responsibilities

• Maintain and support the primary care provider and specialist network to the health plans by developing and maintaining training materials, leading small and large groups, on-site initial training sessions on the policies and procedures of the health plan, problem-solving sessions on managing members in the health plan, writing memorandums, letters, or health plan newsletter articles regarding clarification of covered benefits or procedure changes, researching, evaluating, and responding to individual health care provider requests for exceptions to covered services or pharmaceutical benefits, and resolving urgent or complicated individual situations raised by providers.
• Oversee, support, and assist the case management and other Provider services staff by developing and updating resource materials and comparison grids for easy reference specific to each of the health plans, delegating and assigning job duties, leading biweekly case management meetings to review complicated cases, discussing and revising case management procedures, and informing case management staff of policy changes, providing educational opportunities, and analyzing and determining outcomes for difficult member and/or provider situations.
• Assist in the development and implementation of a quality assurance and utilization review program. Develops new policies and procedures and enforce existing standards. Construct, evaluate, and revise forms in consultation with the Medical Services Director.
• Oversees the administration of the plan benefits and delivery of care by the Providers. Supervises determination of covered benefits for members and develops procedure lists for complex or detailed tasks related to case management.
• Collaborates with the Medical Services Director in developing, maintaining, and updating drug formulary and disease Management protocols for the Health Plans. Develops and implements case management plans and policies for Providers. Provides direct case management services by reviewing requests and authorizing speciality services or exceptions to the drug formulary and/or Protocols.
• Identifies target populations and health-related issues by collecting and analyzing utilization data. Researches standards of care and evidence-based medicine. Analyzes high-cost member reports and collaborates with the information systems analyst to develop and reassess a data information system to track medically complicated and high-cost medical interventions.
• Evaluate and compile complaints from providers, members, or other Health Plan Management Team members to determine a pattern of complaints and initiate a resolution. Initiates further training sessions, better or more frequent phone or written communications, or reassess current policies to control problems.
• Coordinates medical reviews, grievances and appeals. Develops review criteria and communicates with DMS to clarify coverage issues
• Ensures that client records are kept secure and confidential and maintained consistent with Health Department policies and procedures.
• Performs other duties as assigned.

Minimum Requirements

• A fully qualified Nurse with a minimum of 3 years of clinical experience.
• A minimum of 3-7 years experience inclusive of clinical experience, in a Managed Care/HMO variety of health care settings is required.
• Must be a Registered Nurse in Nigeria with a valid certification.
• Works in a standard office environment. Must attend meetings, seminars and speaking engagements throughout the Country.
• Proven experience organizing and directing multiple teams and departments
• Excellent & persuasive communicator – written and oral
• Extremely versatile, dedicated to efficient productivity
• Experience in planning and leading the implementation of strategic initiatives
• Strong data analysis and reporting skills
• Discretion, display of good judgment

Additional Requirements

• Nimble business mind with a focus on developing creative solutions
• Significant experience in conflict resolution and dealing with sensitive issues
• Significant experience working in a highly confidential environment
• High levels of personal resilience and persistence and a significant level of emotional intelligence
• Experience in budget management