Case Manager

The Case Manager is responsible for the clinical analysis of member's care and education to promote knowledge and self-management of the members overall health. The case manager is responsible for coordination of member's care through collaboration with Concurrent Review Nurses, member's immediate and long-term caregiver, member's primary care physician and other internal departments and team members to promote continuity of care. The goal of this position is achieved through communication, supervision and interaction with interdisciplinary care team to promote quality of care and cost-effective outcomes. Knowledge and utilization of health analytic tools is required to identify trends and opportunities to improve satisfaction, quality, utilization and cost.
Duties and responsibilities
Utilization and application of predictive modeling tools and real-time data to perform comprehensive case management outreach with goal of increasing members' abilities to manage their chronic and acute health conditions and decrease unnecessary utilization.
Development of transitional care plans for the member in conjunction with interdisciplinary team members, to and from the acute care setting.
Development of an effective supportive relationship with the member and their family to facilitate achievement of the health goals in conjunction and collaboration with interdisciplinary care teams.
Advocate for patients and their families, providing links to relevant services to help them gain knowledge of their disease processes and to identify community resources for continued growth toward the maximum level of independence.
Conduct outreach calls to members and receive inbound calls from and regarding members in relationship to clinical issues.
Interacts with members to assess their care needs and assists in planning and implementation of interventions to meet those needs.
Analyze data and assist with the process of monitoring clinical program effectiveness.
Participate in clinical management of medical activities to obtain solid clinical history and information.
Performs duties consistent with all regulatory requirements, accreditation organization guidelines, and Integrated Plans guidelines.
Current, valid Registered Nurse/ Licensed Practical Nurse license in the state of practice.
For Nurses - Diploma, A.S. degree or B.S. degree in nursing required. Advanced Degree preferred
For Social worker - B.S degree required and MS degree in social work preferred. Current, active, and unrestricted licensure or certification in a health or human services discipline.
Minimum one (1) year of Utilization Management, Case Management, or equivalent preferred
Knowledge of InterQual/ Milliman Care Guidelines criteria
Prior case management experience within managed care / health plan setting preferred
Excellent communication skills required for interaction with physicians, members, service providers, and internal partners
In depth knowledge of medical/surgical nursing and at least 2 years of experience in clinical practice
Ability to position and pioneer different models of serving members beyond traditional case management.
Strong clinical nursing background and ability to apply critical thinking and problem solving skills.
Experience with Case Management (including planning, implementing, coordinating and monitoring Case Management activities that focus on acute and non-acute services, outpatient services and/or community resources)
Solid computer/PC skills and ability to apply the skills within the scope of this position
Basic to intermediate experience utilizing MS Word, Excel, and Outlook
Current and valid driver's license and reliable transportation
Working conditions
Non-traditional working hours to meet the member's availability and needs
Minimal travel for on-site member/provider meetings, member visits to homes and medical providers, company events, or manager requests

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