Perform care management duties to assess, plan and coordinate all aspects of medical and supporting services across the continuum of care for select members to promote quality, cost effective care.
Walk me through the day-to-day responsibilities of this the role and a description of the project:
Remote telephonic case management, Care manager (CM) follows model of care to assist member in managing health care needs.
Conducts initial assessments, medication review, develops care plan with member, identifies member needs and connects member with appropriate resources to meet health care needs.
Interacts with members care team, community services, vendors.
Follows up with member every 30 days at minimum to review conditions, progress toward goals, and ensure member is receiving requested information and/or services.
Provides education on member health plan and coverage and management of identified health conditions.
Describe the performance expectations/metrics for this individual and their team:
CM caseload expectation is 75 actively managed members, Audit score of 90%or greater, Case duration 90 days.
Tell Me About What Their First Day Looks Like
The first day is usually corporate HR training, setting up company issued equipment and access necessary to perform role specific duties.
What previous job titles or background work will in this role?
RN, experience in case management preferred, clinical nursing background of 5 years or more.
Licenses/Certifications
Current state’s RN license.
Responsibilities
Assess the member's current health status, resource utilization, past and present treatment plan and services, prognosis, short- and long-term goals, treatment, and provider options.
Utilize assessment skills and discretionary judgment to develop plan of care based upon assessment with specific objectives, goals and interventions designed to meet member's needs and promote desired outcomes.
Coordinate services between Primary Care Physician (PCP), specialists, medical providers, and non-medical staff as necessary to meet the complete medical socio-economic needs of clients.
Provide patient and provider education.
Facilitate members’ access to community-based services.
Monitor referrals made to community-based organizations, medical care, and other services to support the members’ overall care management plan.
Actively participate in integrated team care management rounds
Identify related risk management quality concerns and report these scenarios to the appropriate resources.
Case load will reflect heavier weighting of complex cases than Care Manager I, commensurate with experience.
Enter and maintain assessments, authorizations, and pertinent clinical information into various medical management systems.
Direct care to participating network providers.
Perform duties independently, demonstrating advanced understanding of complex care management principles.
Participate in case management committees and work on special projects related to case management as needed.
For New Hampshire, Massachusetts, & Michigan Complete Health - home visits required.
Seniority level
Mid-Senior level
Employment type
Full-time
Job function
Health Care Provider
Industries
Staffing and Recruiting
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