Clinical Case Management Social Worker

Job description

Essential Job Duties and Responsibilities: At International SOS, we are in the business of protecting and saving lives. For 40 years, we have delivered customised security risk management, health, and wellbeing solutions to organisations worldwide. With a presence in 90 countries and a team of nearly 13,000 experts, we provide 24/7 support to help organisations fulfil their Duty of Care responsibilities. Now, we’re looking for talented individuals to join our team and make a difference. Case Management is a collaborative process of assessment, planning, facilitation, care coordination, evaluation and advocacy for options and services to meet an individual’s and family’s comprehensive healthcare needs through collaboration and communication regarding available resources to promote high quality, cost-effective outcomes. The TOP Nurse Case Manager is an integral member of the TRICARE Global Medical Team. The individual is responsible for delivering TOP CM of individuals with high-cost conditions or with specific diseases and conditions. The TOP Case Management Program (CMP) is delivered by the Program Manager and Nurse Case Manager’s. This may be done telephonically and/or face to face to assess, plan, implement and coordinate all case management activities with TRICARE beneficiaries eligible for the TOP Case Management Program. The purpose of the role is to: Take responsibility for newly assigned cases in the CRM system and initiate timely outreach to engage beneficiaries in the TOP Case Management Program (CMP). Provide proactive case management support to TOP beneficiaries by maintaining ongoing contact with individuals who have complex and/or high cost conditions. Support internal quality reviews and semi-annual surveillance audits of the TOP CMP, including monitoring performance, analysing trends, and contributing to service improvement. The core and critical responsibilities of the role includes: To work collaboratively with superiors, peers, and other individuals in the completion of duties – both internal to International SOS as well as with subcontractors, the Defense Health Agency, and the TRICARE beneficiaries we serve. Always ensure a high level of professionalism when dealing with beneficiaries, colleagues, and TRICARE. Ability to work within a remote team to actively drive a high level of service delivery. To apply medical knowledge to high cost, unusual or complex requests for medical care to determine medical necessity and appropriateness. Demonstrate written and oral communication skills to formulate business correspondence and convey complex medical information to other key stakeholders. Maintain an overview of any challenging or complaint cases and escalate to TOP Case Management Program Manager. Management of the TOP CMP: Work in accordance with the TOP Case Management SOP and processes. Manage case assignment and workload using the CRM system dashboard for TOP Case Management. Document beneficiary clinical progress to the client as a case summary note in the CRM system, for discussion at the monthly TOP CMP presentations. Review all allocated new cases for engagement and case management. Attend meetings with the Program Case Manager to discuss cases, request support and guidance and receive role specific training/coaching. Ensure TOP CMP cases are appropriately managed and provide case direction as required. Promote and reinforce the need for evidence-based medical decision making. Escalate billings, policy or claim issues that the beneficiary may be experiencing to the TOP Case Management Program Manager. Case Management Program Delivery: Provide education to beneficiaries regarding the TOP CMP. Conduct proactive, telephonic outreach to beneficiaries with qualifying diagnoses to help with disease education, medication reconciliation and Goals of Care conversations. Source medical referrals on the database system so that beneficiaries are referred to appropriate levels of care. Perform assessments on standards of care tailored to each specific location and medical situation, utilizing all available resources. Provide comprehensive medical advice and recommendations according to each individual medical situation. Communicate with healthcare providers and medical professionals in the region to assess international standards of care being provided to beneficiaries. Review of the medical treatment received or recommended to beneficiaries to ensure it is medically appropriate, authorize cover and issue authorization or a benefit review under the TRICARE policy. Establish care plans and set mutually agreed upon goals with the beneficiary. Develop a proactive course of action to address issues presented to enhance the short and long-term outcomes. When care plan goals are met, or when the beneficiary reports no other needs, or requests disengagement of CM in the case. Client Interaction: Maintain a high level of client and procedural knowledge and ability to engage and interface with the client where appropriate. Participate in monthly TOP CMP case presentations to the TRICARE Area Office Medical Director/s. To participate in semi-annual surveillance audits as required. · To participate in any other client related audits/meetings as required. Reporting: Assist when required with the preparation and/or presentation of other ad hoc reporting regarding the TOP CMP i.e., for semi-annual audits etc. Act as the subject matter expert for reviewing changes to the Standard Operating Procedures (SOPs) assigned to the Case Management Program. Quality : Focus on quality-of-service delivery to ensure that the highest possible levels are achieved. Report to the TOP CM Program Manager the case progress, quality concerns and any other areas of concern and submit feedback to the International SOS customer feedback system as needed. Conduct internal audits of the TOP CMP for monitoring of performance, trend analysis, etc. Manage complaints in a professional manner, resolving them wherever possible or escalating them to the appropriate department. Other Duties: Work within a team and promote all International SOS & TRICARE policies and procedures. Any other duties allocated by the TOP CM Program Manager and/or the TOP Head of Clinical Operations and Policy To work flexible hours as appropriate to the needs of the post. To recognise limitations and areas of self-development through reflection. To be responsible for all actions and decisions made, knowing when to defer or escalate to other senior members of the quality and medical teams. Keeps own operational technical / functional skills and knowledge up to date. Be responsible for own Continuing Professional Education. International SOS will endeavour to support appropriate Continuing Professional Education requests. Attend supervision, training, and departmental meetings as and when required. Undertake accountability for workload. To keep accurate records. Required Skills and Knowledge (Brief description of technical knowledge or skills needed to perform the job) Attention to detail. Broad Medical Knowledge. Previous experience in clinical case management desirable Effective communication skills: Exercise’s discretion and judgment when providing feedback, guidance, and clarification to ensure the relationship is protected. Converses fluently in English. Ability to provide clear and concise written updates in English. Identifies and acts on potential problems and / or difficulties. Demonstrates appropriate listening skills. Demonstrates effective problem-solving skills and lateral thinking. Able to work under pressure and to prepare accurate and timely reports in line with the requirements of the TOP. Working knowledge of Microsoft Office applications and the ability to learn and work with International SOS and subcontractor databases and software. Knowledge or familiarity with the TRICARE Overseas Program (preferred). Positive motivation, encouragement, and influence skills Required Competencies (Critical behaviors necessary to successfully perform the job) Customer service oriented. Empathetic and able to positively influence the customer journey experience. Team player. Has initiative, takes responsibility. Ability to work independently. Required Qualifications (Brief description of the educational background needed to perform the job) 3+ years LCSW experience required. Licensed Clinical Social Worker qualification and licensure Case Management certification by a recognised US body Managed care experience preferred. TRICARE experience preferred. Required Languages (Brief description of the language skills needed to perform the job) Excellent spoken and written English. Additional language skills (particularly Spanish) are desirable, but not essential Travel / Rotation Requirements (Brief description of any travel or rotation requirements) Flexible hours as appropriate to the needs of the post. None required