SCOPE OF ROLE

The role of the Care 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 members receive services and resources required to meet desired health and social outcomes. The Care Manager is responsible for providing patient-centered care across the care continuum.

ROLE RESPONSIBILITIES 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 and self-management.
• Capacity to coordinate interdisciplinary team meetings as required
• Collaboration across providers and healthcare settings to ensure optimal quality outcomes for an assigned population
• Provide transition of care interventions as required 10% 6. Facilitate care coordination, self-management planning, discharge planning, and health education for an assigned population.
• Facilitate linkage to appropriate community resources to address social determinants of health
• Capacity to adjudicate referrals and apply evidence-based clinical criteria to coordinate member care needs across all care setting
• Able to 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.

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

LICENSURES AND CERTIFICATIONS

• Active and Unrestricted License as a Registered Nurse (RN)
• Certification in Case Management (CCM) or Managed Care Nursing (CMCN) preferred

WORK ENVIRONMENT

• The majority of work responsibilities are performed in an open office setting, carrying out detailed work sitting at a desk/table and working on the computer.
• Some travel may be required.