Review clinicals, claims and baseline case information for health scenarios such as Behavioral, Wellness, and Specialty Prescription, Maternity etc.
Develop strategic, initiative care plans to support members with varying health scenarios by connecting them to specialized vendor partners and Allied Care Clinicians that can facilitate the needs of the member.
Implement the care plan by coordinating with the member, client, Allied staff and/or the various specialized vendor partners.
Work closely with the Clinical Case Management team and other Case Managers to obtain clinical information needed to support the care plan.
Communicate with (CMS) to obtain essential member information.
Facilitate and maintain prescription drug vendor relationships, negotiate pricing as needed, manage member set-up, and provide on-going support.
Document the impact of the casework to highlight cost savings and the improvement of member health outcomes as a result of implanting a plan of care.
Perform assorted weekly and monthly administrative tasks.
Act as the liaison between the client/broker/member and Allied Executives and Various Departments.
Troubleshoot, identify, and collaborate to optimize internal processes within Enhanced Case Management and the various Allied departments.

Bachelor’s degree or equivalent work experience required.
2 years of experience with Group Health Insurance and Self-Funded Health Plans required.
Excellent verbal and written communication skills.
Excellent interpersonal and customer service skills.
Excellent organizational skills and attention to detail.
Excellent time management skills with a proven ability to meet deadlines.
Ability to review information, assess the problem, and propose viable solutions.
Strong analytical and problem-solving skills.
Medicare, Medicaid, Case Management and prescription drug benefit experience preferred.
Experience in a clinical or social work position a plus.
Experience working in a hospital system a plus.
Life and Health Insurance Producers License is preferred, but not required.
Proficient with Microsoft Office Suite or related software.

Case Manager, Benefits & Care Navigation

Key skills