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We are transforming healthcare to be value-driven, creating a seamless, consumer-centric care experience that maximizes value for all.
We believe that all health consumers are entitled to high quality, coordinated healthcare. We uniquely align the interests of health consumers, providers, and payors to make high-quality healthcare accessible and affordable to all populations across the ACA Marketplace, Medicare, and Medicaid.
The role of the Case Manager is to promote quality, cost-effective outcomes for a population by facilitating collaboration and coordination across settings, assessing member needs, planning for care, monitoring the efficacy of interventions, and advocating to ensure member's receive services and resources required to meet desired health and social outcomes. The Case Manager is responsible for providing patient centered care across the care continuum.
ROLE RESPONSIBILITIES
- Assessment of the medical, social, and behavioral needs of an assigned population
- Care Plan development and prioritization to transition members to optimal levels of health andself-management
- Coordinate interdisciplinary team meetings as required
- Collaboration across providers and healthcare settings to ensure optimal quality outcomes for anassigned population
- Provide transition of care interventions as required
- Facilitate care coordination, self-management planning, discharge planning, and healtheducation for an assigned population
- Facilitate linkage to appropriate community resources to address social determinants of health
- Adjudicate referrals and apply evidence-based clinical criteria to coordinate member care needs across all care setting
- Ensure member communication and notices are composed in a manner consistent with regulatory standards.
- Adheres to the Policies and Procedures set forth by the Quality Management Committee andperforms all additional duties as assigned.
EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE
- Associate's degree in Nursing, Bachelor's degree preferred
- Minimum 2 years of experience in medical management clinical functions.
- Working knowledge of MCG, InterQual, and NCQA standards
- Bilingual in English and Spanish is required.
LICENSURES AND CERTIFICATIONS
- Active and Unrestricted License as a Registered Nurse (RN). COMPACT RN License required.
- Certification in Case Management (CCM) or Managed Care Nursing (CMCN) preferred
PROFESSIONAL COMPETENCIES
- * High level of critical thinking and problem-solving skills
- * Strong work ethic and overall positive attitude
- * Effective communication skills including verbal and written
- * Ability to manage time effectively, understand directions, and work independently in a fast-paced environment
- * Demonstrated flexibility, organization, and self-motivation
- * Highly adaptable to change