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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

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.

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.