Healthcare Consultant II

Job Title: Healthcare Consultant II - Jefferson County KY

Looking for Kentucky. Must reside in Jerfferson County.
WFH position

Add City, State and County at top of resume.

Job Description:
The Care Management Associate supports comprehensive coordination of medical services including Care Team intake, screening and supporting the implementation of care plans to promote effective utilization of healthcare services. Promotes/supports quality effectiveness of Healthcare Services.
This is a telework position and this position is assigned to the Jefferson Region. Qualified candidates must reside in Jefferson County. 5% - 10% travel is required to the Louisville office for meetings, training, and administrative duties.

Fundamental Components:
Responsible for initial review and triage of Care Team tasks.
Identifies principle reason for admission, facility, and member product to correctly apply intervention assessment tools.
Screens patients using targeted intervention business rules and processes to identify needed medical services, make appropriate referrals to medical services staff and coordinate the required services in accordance with the benefit plan.
Monitors non-targeted cases for entry of appropriate discharge date and disposition.
Identifies and refers outlier cases (e.g., Length of Stay) to clinical staff.
Identifies triggers for referral into Aetna\'s Case Management, Disease Management, Mixed Services, and other Specialty Programs.
Utilizes Aetna systems to build, research and enter member information, as needed.
Support the Development and Implementation of Care Plans.
Coordinates and arranges for health care service delivery under the direction of nurse or medical director in the most appropriate setting at the most appropriate expense by identifying opportunities for the patient to utilize participating providers and services.
Promotes communication, both internally and externally to enhance effectiveness of medical management services (e.g., health care providers, and health care team members respectively).
Performs non-medical research pertinent to the establishment, maintenance and closure of open cases.
Provides support services to team members by answering telephone calls, taking messages, researching information and assisting in solving problems.
Adheres to Compliance with PM Policies and Regulatory Standards.
Maintains accurate and complete documentation of required information that meets risk management, regulatory, and accreditation requirements.
Protects the confidentiality of member information and adheres to company policies regarding confidentiality.
May assist in the research and resolution of claims payment issues.
Supports the administration of the hospital care, case management and quality management processes in compliance with various laws and regulations, URAQ and/or NCQA standards, Case Management Society of America (CMSA) standards where applicable, while adhering to company policy and procedures.

Work from Home Requirements:
You must have or be able to obtain a direct/hardwired internet connection to a modem/router within 7 feet of your computer and a minimum download speed of 25 mbs download and 3 mbs upload. WiFi and satellite internet are not permitted.
A quiet, secure and private designated home virtual work location, free from distractions, tidy and organized, compliant with Health and HIPAA guidelines, and allowing for uninterrupted work during work hours.
Work-from-Home colleagues are required to work within the state and city where they have confirmed they currently live.
The company will provide equipment (keyboard, monitor, computer, headset, etc.). All new hires should provide their own workspace furniture (desk or standing desk, as this position would require you to be at your desk for extended periods of time).
If hired, you will commit to obtaining required internet speeds and adhere to all Work From Home requirements.

Technical and Logistical Requirements:
Device & System Navigation: Comfortable setting up and using multiple monitors and navigating multiple applications simultaneously to streamline tasks and improve efficiency.
Communication Tools: Ability to communicate on digital channels such as via email, calendar invites, Teams messaging, and virtual meetings.
Collaboration & Scheduling: Experience with Microsoft Office 365 (Teams, Outlook, Word, Excel, PowerPoint) applications or similar (Google Workspace).
Systems Access & Security: Ability to Log in to secure systems (e.g., VPN, EHR portal), lock a computer screen when unattended, manage strong passwords, and recognize suspicious emails or links.
Troubleshooting & Support: Ability to resolve common technical issues independently, such as: restarting an application when frozen, resolving internet connection issues, and contacting IT for unresolved technical issues.
Future Growth: Openness to learning new skills in the future as the workplace environment evolves

Background/Experience Desired:
Experience or detailed knowledge of the Foster Care and juvenile justice systems, Adoption Assistance, the delivery of Behavior Health Services, Trauma-informed Care, ACEs, Crisis Intervention services, and evidence-based practices applicable to the Kentucky SKY populations, is required.
2-4 years experience as a medical assistant, office assistant.
Computer literacy and demonstrated proficiency is required in order to navigate through internal/external computer systems, and MS Office Suite applications, including Word and Excel.
Effective communication, telephonic, and organization skills.
Familiarity with basic medical terminology and concepts used in care management.
Strong customer service skills to coordinate service delivery including attention to customers, sensitivity to issues, proactive identification and resolution of issues to promote positive outcomes for members.
Ability to effectively participate in a multi-disciplinary team including internal and external participants.

Education and Certification Requirements:
High School Diploma or G.E.D.

Duties
Determines medical necessity/ appropriateness
Facilitates optimal outcomes
Identifies and follow through with continuous quality/ compliance opportunities . May also include identification of aberrance\'s and initiation of corrective action
Educates/ empowers customers to ensure compliance, satisfaction and promote patient advocacy
Optimize total costs
Implementation and evaluation of policy based on usage and program directives
Educate/empower colleagues at all levels to enable decision making at most appropriate level

Experience
Minimum 3 years of relevant experience

Position Summary
Provide comprehensive healthcare management services to facilitate appropriate healthcare treatment, effectively
manage healthcare costs and improve healthcare program/operational efficiency involving clinical issues

Education
High School Diploma or GED

What days & hours will the person work in this position List training hours, if different.
Mon-Friday 8:00-5:00pm with the flexibility to work until 6:00pm EST.