Transitional Care Management Jobs in Oregon (NOW HIRING)

It’s an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.

Job Summary

The Clinical Care Manager provides holistic care management services for members throughout the continuum of care by assessing the member clinically as well as member’s readiness to make behavioral changes and actively participate in a care plan, establish goals and meet those goals. Wellsense Health Plan members may include those who have chronic conditions and complex care needs, including those considered to be the highest risk members those who are homeless, undergoing organ transplantation, have multiple clinical and behavioral co-morbid conditions, and with special health care needs. The clinician works collaboratively with a multidisciplinary team (both internal and external) including providers, our clinical vendor partners (pharmacy, etc.) and community/State agencies to increase patient knowledge, motivation, and compliance with treatment through targeted interventions that address the member’s holistic needs from a medical and psychosocial/socioeconomic standpoint. Following this approach, the goal is to improve member health outcomes and decrease overall cost while improving the member’s overall experience with the health care delivery system.

Utilizing both telephonic outreach and face to face member visits and through the use of assessments, real-time data, motivational interviewing techniques and evidence-based practices, the Clinical Care Manager engages with the member and the multidisciplinary team to develop an Individualized Care Plan (ICP) that emphasizes self-management goals, care coordination, psychosocial, socioeconomic, and community-based supports and on-going monitoring and appropriate follow up. The Clinical Care Manager identifies and addresses barriers to optimal self-management and works with the member, their support persons, and team to coordinate care throughout the health care continuum, assisting the member to access all available benefits and resources including family support and community resources, with a goal of promoting appropriate utilization of services at the appropriate level and site of care such as preventing ambulatory sensitive emergency department visits and inpatient admissions, avoiding readmissions, and encouraging the member to keep scheduled outpatient appointments to include preventive care visits.  The clinical care manager may meet members in their homes, shelters, provider offices, medical facilities, and at locations agreed upon with the member. Position requires approximately 50% or greater travel to conduct in-person transitions-of-care member visits across Hampden and Worcester, or Suffolk counties. Mileage reimbursement is provided at the applicable IRS rate.

Our Investment in You:

·       Full-time hybrid work

·       Competitive salaries

·       Excellent benefits

Key Functions/Responsibilities

·       Supports programs and clinical best practices with the objective of improving health outcomes, preventing hospital readmissions, improving member safety and reducing medical errors, and promoting health and wellness activities, where appropriate.

·       Completes a transitional care management assessment and applicable condition specific assessments.

·       Collaborate with hospitals to ensure a seamless transition of care upon admission and discharge to the community, and detail information sharing and collaboration between the Health Plan and the participating hospital

·       Coordinates member care transitions through pre-admission assessments, post-discharge assessment and follow-up to ensure appointment is made with the PCP or Specialist; assessing for home health services, DME needs, and transportation issues; performing medication reconciliation; ensuring compliance with discharge plan, appointments and medication regimen.

·       Uses available standardized educational materials in an appropriate reading level to educate members about their conditions.

·       Monitor members’ labs, tests results, appointments and other data in order to best coordinate care utilizing EMR (where available and appropriate) and the Plan’s care management software.

·       Evaluates members’ need for complex care management, disease management or care management services.

·       Collaboratively develops an individualized care plan with the member focusing on the member’s goals and objectives, identifying strategies, supports and/or services needed to achieve short and long term goals.

·       Identifies and addresses barriers to optimal self-management and works with the member and team to coordinate care throughout the health care continuum.

·       Assists the member to access all available benefits and resources including family support and community resources.

·       Utilizes motivational interviewing techniques to engage members in care management and to coach members regarding health promotion, disease management and preventive health strategies.

·       Uses real-time data from electronic medical records, where available.

·       Uses Wellsense Health Plan reporting to access member medical and pharmacy utilization reports, sharing with PCP, to promote medication compliance and action plans.

·       Supports and enhances the member’s capacity to self-manage.

·       Evaluates the effectiveness of the care management provided to the member on an on-going basis and updates the ICP accordingly.

·       Utilizes evidence-based practices and guidelines to educate members on specific disease processes.

·       Provides or arranges for resources necessary to meet members’ psychosocial and socioeconomic needs.

·       Promotes and encourages member collaboration with the primary care provider and other health care providers.

·       Completes documentation in the medical management information system real-time during face-to-face meetings, by phone, and in a timely manner and in keeping with contractual requirements, internal policy and NCQA accreditation standards.  Facilitates multidisciplinary consultation on members’ behalf through participation in rounds, team meetings and clinical reviews.

·       Conducts face-to-face visits with members and providers, community and state agencies, as appropriate.

·       Assists with staff training and mentoring.

·       Maintains HIPPA standards and confidentiality of protected health information.

·       Demonstrates strong knowledge of contractual requirements of all Wellsense products and provides cross coverage across product lines when needed.

·       Adheres to departmental/organizational policies and procedures.

·       Other duties as assigned.

Supervision Exercised

·       None

Supervision Received

·       Regularly scheduled meetings with Manager of Care Management

Qualifications

Education Required:

·       Bachelor’s degree in nursing or Associate’s degree in Nursing and relevant work experience.

Experience Required: 

·       3 years related experience in home health care or managed care organization

·       3 years clinical experience working with members who have multiple, chronic or complex health conditions

·       2 years’ experience in care management, care coordination and/or discharge planning

Experience Preferred/Desirable: 

·       Experience working with Medicaid recipients and community services

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