Care Manager – Transitions of Care

Role Overview

• The Care Manager collaborates with members of an inter-disciplinary care team (ICT), providers, community and faith-based organizations to improve quality and meet the needs of the individual, natural supports and the population with culturally competent delivery of care, services and supports.
• Facilitates communication, coordinates care and service of the member through assessments, identification, person-centered planning, assist the member in creation and evaluation of person-centered care plans to prioritize and address what matters most, behavioral, physical and social determinants of health needs with the aim to improve the of lives our members.
• Engage the member and their natural support system through strength-based assessments and a trauma-informed care approach using motivation interviewing to complete health and psychosocial assessments through a health equity lens unique to the needs of each member that identify the cultural, linguistic, social and environmental factors/determinants that shape health and improve health disparities and access to public and community health frameworks.
• Facilitate regularly scheduled inter-disciplinary care team (ICT) meetings to meet the needs of the member.
• Engage with the member to establish an effective, professional relationship via telephonic or electronic communication.
• Develop and regularly update a person-centered individualized care plan (ICP) in collaboration with the ICT, based on member’s desires, needs and preferences.
• Identify and manage barriers to achievement of care plan goals.
• Identify and implement effective interventions based on clinical standards and best practices.
• Assist with empowering the member to manage and improve their health, wellness, safety, adaptation, and self-care through effective care coordination and case management.

Requirements

• Nursing degree from an accredited nursing program or Bachelor’s degree in a health care field or equivalent years of relevant work experience
• A minimum of three (3) years of experience in nursing or social work or counseling or health care profession (i.e. discharge planning, case management, care coordination, and/or home/community health management experience)
• Three (3) years Medicaid and/or Medicare managed care experience is preferred
• Strong understanding of Quality, HEDIS, disease management, supportive medication reconciliation and adherence
• Intermediate proficiency level with Microsoft Office, including Outlook, Word and Excel
• Knowledge of local, state & federal healthcare laws and regulations & all company policies regarding case management practices
• Current unrestricted clinical license in state of practice as a Registered Nurse, Social Worker or Professional Clinical Counselor is required.

Benefits

• Health insurance
• 401(k) matching
• Flexible work hours
• Paid time off
• Remote work options