Case Coordinator

• Monitor and manage care coordination initiatives
• Help DWIHN, its provider network, and the healthcare community progress toward a holistic, integrated, broad-ranging service model
• Follow NCQA guidelines for Complex Case Management
• Maintain a caseload of DWIHN members
• Complete required documentation in MHWIN within required time frames
• Visit members in hospital or community settings
• Complete assessments and plans of care within required time frames
• Identify eligible members through hospital inpatient lists, EMS lists, PHQ, hospital recidivism, and other sources
• Oversee marketing and education of Wayne County community providers
• Receive and respond to complex case management referrals within designated time frames
• Complete weekly and monthly reports
• Provide transitions-of-care support for members discharged from acute care settings
• Maintain compiled member lists/data for reporting requirements
• Coordinate with member care teams at the community level
• Connect members with community resources and health providers
• Assist members with applications for health benefits, SSI, Bridge Card, and related support
• Participate in care review mock audits and file reviews
• Provide care coordination for members not eligible for Complex Case Management
• Attend weekly team meetings, all-staff meetings, DWIHN meetings, designated CRSP/COPE/Children/Hospital Liaison meetings, and required training
• Perform related duties as assigned

Complex Case Coordinator

• Collaborate and inform the case management process
• Facilitate appropriate healthcare outcomes for members
• Assist with appointment scheduling
• Identify and assist members with accessing benefits and education using care management tools and resources
• Evaluate members' needs, eligibility, benefit plans, and available programs or services
• Identify high-risk factors and service needs and refer to clinical case management or crisis intervention as appropriate
• Coordinate and implement assigned care plan activities and monitor progress
• Consult with case managers, supervisors, Medical Directors, and other health programs to overcome barriers
• Present cases at case conferences for multidisciplinary review
• Identify and escalate quality-of-care issues
• Negotiate appropriate options and services for members' benefits and healthcare needs
• Use influencing and motivational interviewing skills to promote member engagement and behavior changes
• Provide coaching, information, and support for independent medical and healthy lifestyle choices
• Engage in team meetings and provide peer mentoring/training
• Help members participate knowledgeably in healthcare decision-making
• Use case management and quality management processes in compliance with regulatory, accreditation, and company requirements

Case Management Coordinator – Field

• Conduct comprehensive evaluations of members’ needs and eligibility using care management tools and information/data review
• Recommend approaches to case resolution and meeting member needs by evaluating benefit plans and available programs/services
• Identify high-risk factors and service needs and refer members to clinical case management or crisis intervention as appropriate
• Coordinate and implement assigned care plan activities and monitor progress
• Consult with case managers, supervisors, Medical Directors, and other health programs to overcome barriers
• Present cases at case conferences for multidisciplinary review
• Identify and escalate quality-of-care issues through established channels
• Negotiate appropriate options and services for members’ benefits and healthcare needs
• Use influencing and motivational interviewing skills to engage members and promote lifestyle/behavior changes
• Provide coaching, information, and support to empower independent medical and healthy lifestyle choices
• Engage in team meetings and provide peer mentoring/training
• Help members participate knowledgeably with providers in healthcare decision-making
• Apply case management and quality management processes in compliance with regulatory, accreditation, and company requirements

• Manage complex cases in the community across child-serving systems
• Conduct comprehensive evaluations of referred members’ needs and eligibility
• Evaluate benefit plans and internal and external programs/services
• Identify high-risk factors and service needs and make appropriate referrals
• Coordinate and implement assigned care plan activities
• Monitor care plan progress
• Consult with case managers, supervisors, Medical Directors, and health/behavioral health programs to overcome barriers
• Present cases at case conferences for multidisciplinary review
• Collaborate with members’ Child and Family Teams
• Identify and escalate quality-of-care issues
• Negotiate appropriate options and services to meet members’ benefits and healthcare needs
• Use motivational interviewing to promote member engagement and behavior change
• Provide coaching, information, and support for independent medical and healthy lifestyle choices
• Help members participate knowledgeably in healthcare decisions with providers
• Serve as a single point of contact and remediate immediate gaps in care and access
• Apply case management and quality management processes in compliance with regulatory, accreditation, and company requirements

Case Management Coordinator, Field

• Conduct comprehensive evaluations of referred members’ needs and eligibility
• Evaluate benefit plans and internal and external programs/services
• Identify high-risk factors and service needs and make appropriate referrals
• Coordinate and implement assigned care plan activities and monitor progress
• Consult with case managers, supervisors, Medical Directors, and health/behavioral health programs to overcome care barriers
• Present cases at case conferences for multidisciplinary review
• Collaborate with members’ Child and Family Teams
• Identify and escalate quality-of-care issues
• Negotiate appropriate options and services to meet member benefits and healthcare needs
• Use motivational interviewing to maximize member engagement and promote healthy behavior changes
• Provide coaching, information, and support for independent medical and healthy lifestyle choices
• Help members participate knowledgeably in healthcare decision-making with providers
• Serve as a single point of contact and remediate immediate gaps in care and access
• Use case management and quality management processes in compliance with regulatory, accreditation, and company requirements

• Facilitate appropriate healthcare outcomes for members through appointment scheduling, benefits access, and member education
• Evaluate member needs, eligibility, benefit plans, and available programs or services
• Identify high-risk factors and service needs, with referral to clinical case management or crisis intervention as appropriate
• Coordinate assigned care plan activities and monitor care plan progress
• Consult with case managers, supervisors, Medical Directors, and other health programs to overcome barriers
• Present cases at case conferences for multidisciplinary review
• Identify and escalate quality-of-care issues
• Negotiate appropriate options and services for members
• Use influencing and motivational interviewing skills to engage members and promote lifestyle or behavior changes
• Provide coaching, information, and support for independent medical and healthy lifestyle choices
• Participate in team meetings and provide peer mentoring/training
• Help members participate knowledgeably in healthcare decision-making
• Use case management and quality management processes in compliance with regulatory, accreditation, and company guidelines

• Provide excellent customer service and internal support to an assigned team
• Manage workers’ compensation claims caseload under supervision and in collaboration with the Clinical Case Management Team
• Collect and document data for workers’ compensation claims while following workflow and company guidelines
• Process and facilitate necessary treatment services according to company policy and procedure
• Verify return-to-work and remain-at-work status through routine communication with claim parties and documentation in the claim management system
• Use telephonic and written communications to accurately report return-to-work dates
• Maintain knowledge of Bureau of Workers’ Compensation rules and laws, workers’ compensation processes, and Sedgwick policies and procedures

• Provide excellent customer service and internal support to an assigned team
• Manage workers’ compensation claims caseload under supervision and in collaboration with the Clinical Case Management Team
• Collect and document data for workers’ compensation claims
• Process and facilitate necessary treatment services according to company policy and procedure
• Verify return-to-work and remain-at-work status through communication with claim parties and documentation in the claim management system
• Use telephonic and written communications to accurately report return-to-work dates
• Maintain knowledge of Bureau of Workers’ Compensation rules and laws, workers’ compensation processes, and Sedgwick policies and procedures

• Provide active care management and assess members’ service needs
• Develop, coordinate, monitor, and evaluate member-centered action plans
• Assess eligibility, benefit levels, place of service, length of stay, medical necessity, and benefit exceptions
• Document clinical information supporting medical necessity and contract benefits
• Provide telephonic support for members with chronic conditions, high-risk pregnancy, and other at-risk conditions
• Deliver condition-specific education and member-centered coaching using motivational interviewing, reflective listening, and readiness-to-change assessment
• Educate and intervene directly with members and providers regarding health care delivery, networks, and benefit plans
• Identify, initiate, and participate in on-site reviews
• Advocate for members through continued communication and education
• Promote enrollment in care management and health and disease management programs
• Communicate requested-service information to health care providers and members in writing and by telephone
• Perform medical or behavioral review and authorization processes
• Ensure service coverage complies with benefit and medical necessity guidelines
• Make referrals to Medical Directors, Case Managers, Preventive Services, Subrogation, and Quality of Care teams
• Collect and input clinical information for proper claims adjudication
• Comply with ERISA, NCQA, URAC, DOI, DOL, and other applicable regulations
• Maintain current knowledge of contracts and provider network status
• Assist with claims information, discussion, and resolution; refer issues to internal support areas

Case Management Coordinator, Maternity Focus

• Collaborate with members, providers, and community organizations to address healthcare and social determinant needs
• Facilitate appropriate healthcare outcomes by assisting with appointment scheduling and access to benefits and member education
• Conduct comprehensive evaluations of referred members’ needs and eligibility using care management tools and data review
• Evaluate benefit plans and internal and external programs/services to recommend case-resolution approaches
• Identify high-risk factors and service needs, referring to clinical case management or crisis intervention as appropriate
• Coordinate and implement assigned care plan activities and monitor progress
• Consult with case managers, supervisors, Medical Directors, and other health programs to overcome barriers
• Present cases at case conferences for multidisciplinary review
• Identify and escalate quality-of-care issues through established channels
• Negotiate appropriate options and services to meet members’ benefits and healthcare needs
• Use motivational interviewing to promote member engagement, lifestyle, and behavior changes
• Provide coaching, information, and support for independent medical and healthy lifestyle choices
• Help members participate knowledgeably in healthcare decisions with providers
• Apply case management and quality management processes in compliance with regulatory, accreditation, and company requirements
• Interact with members/clients telephonically or in person, including possible visits to homes, worksites, or physicians’ offices