RN Care Manager

Job Title

Care Manager

Position Location:

DE, Working at Home – Delaware

Responsibilities and Duties:

This job owns and conducts oversight over a specified panel of members that range in health status/severity and clinical needs. The incumbent assesses health management needs of the assigned member panel and utilizes data/analytics, in conjunction with professional clinical judgement, to identify the right clinical intervention for each member. The incumbent is supported by a multi-disciplinary team and uses clinical judgment to refer members to appropriate multi-disciplinary resources. In addition to identifying the appropriate clinical interventions and referrals, the incumbent manages an active case load of members in their panel that are enrolled in case management. The incumbent conducts outreach to members enrolled in case management including but not limited to: developing a care plan, encouraging behavior changes, identifying and addressing barriers, helping members to coordinate care, and identifying various resources to assist members in achieving their personal health goals. The incumbent monitors, improves and maintains quality outcomes (clinical, financial and functional) for the specified panel of members.

ESSENTIAL RESPONSIBILITIES

• Maintain oversight over specified panel of members by performing ongoing assessment of members’ health management needs, identifying the right clinical interventions to address member needs and/or triaging members to appropriate resources for additional support.
• For assigned case load, create care plans to address members’ identified needs, remove barriers to care, identify resources, and conduct a number of other activities to help improve the health outcomes of members; care plans include both long and short term goals and plan of regular contacts for re-assessment.
• Ensure targeted percentage of patient goal achievement (i.e., realization of member care plan), and other patient outcomes, as applicable, are achieved.
• Ensure all activities are documented and conducted in compliance with applicable business process requirements, regulatory requirements and accreditation standards.
• Maintain current knowledge and adheres to applicable CMS, state, local, and regulatory agency requirements and applicable standards of practice for case management including those published by CMSA and/or ACMA, as required by the organization.
• Other duties as assigned or requested.

Required Qualifications:

• Educational requirements: High School Diploma/GED
• Professional experience, skills and qualifications:
  • 7 years of any combination of clinical, case management and/or disease/condition management experience, provider operations and / or health insurance experience
  • RN license in DE.
  • Written and verbal presentation skills, negotiation skills, and skills in positively influencing others with respect and compassion
  • Broad knowledge of disease processes
  • Understanding of healthcare costs and the broader healthcare service delivery system
  • Proficiency in MS Excel and computer skills.
  • Strong analytic skills with ability to interpret, evaluate and act on clinical and financial data, including analysis of statistical data
  • Excellent interpersonal/ consensus building skills as well as the ability to work with a variety of internal and external colleagues from all levels of an organization
  • Ability to work in a high performing team environment that requires flexibility
  • Demonstrated ability to handle multiple priorities in a fast paced environment. Excellent organizational, time management, problem solving, and project management skills
  • Self-directed; self-starter, ability to work successfully with indirect supervision and moderate autonomy

Preferred Qualifications:

• Educational requirements: Bachelor’s Degree in Nursing
• Professional experience, skills and qualifications:
  • Advanced training and experience in cognitive behavioral therapy (CBT), motivational interviewing or dialectical behavior therapy (DBT)
  • Experience working with the healthcare needs of diverse populations
  • Understanding of the importance of cultural competency in addressing targeted populations
  • Experience working at either Quantum or Accolade
  • Certification in Case Management