Medical Case Manager (Remote)

View full description

Requirements:

• Bachelor’s degree in nursing or RN certification in lieu of bachelor's degree or Master’s degree in Social Work, Counseling, Education, or related field and 3 years' experience in Acute or Managed Care/ experience with Medicaid or Medicare populations.
• OR Bachelor’s degree in Social Work with five years’ experience in Acute or Managed Care/ experience with Medicaid or Medicare populations
• Experience working with high-risk pregnant women OR experience working with chronic condition adult populations OR experience with pediatrics
• 3 years of experience in working in Acute Care/Managed Care/Medicaid and Medicare populations.
• Bilingual English/Spanish language skills (Preferred)
• Case Management Certification (Preferred)

Responsibilities:

• Communicate effectively while performing customer telephonic interviewing and communication with external contacts.
• Communicate effectively while interacting with Case Management Specialists, Management Team, Physician Advisors and other interdepartmental contacts.
• Maintain knowledge of Medical Terminology and Medical Diagnostic Categories/Disease States
• Educate members to enhance member understanding of illness/disease impact and to positively impact member care plan adherence, pharmacy regimen maintenance, and health outcomes.
• Collaborate with Primary Care Physicians, Medical Specialists, Home Health and other ancillary healthcare providers with the goal being to coordinate member care.
• Collect member medical information from a variety of sources including providers and internal records and use appropriate clinical judgment, consultation with internal Physician Advisors and other internal cross-departmental consultation to determine unmet member needs.
• Work primarily independently to identify, define, and resolve a myriad of problem types experienced by the member.
• Develop an individualized plan of care designed to meet the specific needs of each member.
• Anticipate the needs of members by continually assessing and monitoring the member’s progress toward goals, care plan status, and re-adjust goals when indicated.
• Maintain a working knowledge of available resources for addressing identified member needs and to facilitate proactive and efficient provision of services.
• Be knowledgeable of and consider benefit design and cost benefit analysis when planning a course of intervention to develop a realistic plan of care.
• Communicate and collaborate with other payers (when applicable) to create a collaborative approach to care management and benefit coordination.
• Maintain a working knowledge of available community resources available to assist members.
• Coordinate with community organizations/agencies for the purpose of identifying additional resources for which the MCO is not responsible.
• Work within a Team Environment.
• Attend and participate in required meetings, including staff meetings, internal Rounds, and other in-services to enhance professional knowledge and competency for overall management of members.
• Participate in departmental and/or organizational work and quality initiative teams.
• Case collaborate with peers, Case Management Specialists, Management Team, Physician Advisors and other interdepartmental contacts.
• Participate in interagency and/or interdisciplinary team meetings when necessary to facilitate coordination of member care and resources.
• Foster effective work relationships through conflict resolution and constructive feedback skills.
• Attend internal and external continuing education forums annually to enhance overall clinical skills and maintain professional licensure, if applicable.
• Educate health team colleagues of the role and responsibility of Case Management and the unique needs of the populations served to foster constructive and collaborative solutions to meet member needs.
• Other duties as assigned or requested.