Job Description The scope of the High-Risk Case Manager is to effectively manage members on an outpatient basis to ensure the appropriate level-of-care is provided for complex and chronic care needs by assessing, developing, implementing, coordinating, monitoring, and evaluating care to prevent re-admissions and ensure that the members' medical, environmental and psychosocial needs are optimize over the continuum of care. Responsibilities Identifies appropriate members for case management and conducts assessments to identify individual needs and a specific care management plan to address objectives and goals as identified during assessment.|Develop Individual Care Plan (ICP) by conditions identified in health plan HRA, patient assessment, medical records authorizations/referrals, primary care physician, member, and Interdisciplinary Care Team (ICT). Setting members prioritized and self-management goals.|Case Manager's ability to effectively manage a panel/caseload of high-risk members in collaboration with Nurse Practitioner, Pharmacist, PCP, SPC, health plans and other ICT members.|Create cases in Essette for each case managed member with appropriate documentation including but not limited to; cognitive, functional, ADL, environmental factors, psychosocial, medical and benefits etc.|Provides appropriate documentation including but not limited to; cognitive, functional, ADL, environmental factors, psychosocial, medical and benefits etc.|Collaborate with member's family and physicians for seamless coordination of care and services|Collaborate and coordinate care with Health plans, Community Based Programs (CBAS), Managed Long Term Supportive Services (MLTSS) and Behavioral Health Providers|Monitors and evaluate effectiveness of the care management plan and modify as necessary based on members' progress, changes in condition and to minimize unnecessary utilizations, admissions, and readmissions. Interfaces with Medical Director and attends IDT as required.|Conducts outbound calls to assigned high risk case managed members. Occasional, in person visit may be needed to better facilitate members' care.|Collaborate with member, member's family, and physicians for seamless coordination of care and services.|Collaborate and coordinate care with health plans, Community Based Programs (CBAS), Multiple Long Term Support Services (MLTSS) and Behavioral Health providers. Meet health plans and NCQA requirements in turn-around-time for assessments, care plans and IDTs. Qualifications At least two (2) years' experience in the medical field required. One (1) year experience in a case management role required. At least two (2) years' experience in ambulatory case management, preferably in a managed care organization, medical group, or health plan setting required.Knowledgeable in NCQA requirements preferred.Graduate of accredited nursing programCCM Certification preferred.RN/LVN unrestricted active license required.
