Care Manager
*This is a remote position
*Must reside in the U.S. and hold an active license in your state of residence
*Monday 8 or 8:30 AM CST, 4:30 PM or 5 PM
Description:
- This position is responsible for the assessment, reassessment, care planning and coordination of care and services including ongoing monitoring of an appropriate and effective person-centered care plan, member education and care management.
- Conducts initial and concurrent review for prior authorization of higher levels of care against medical necessity criteria.
- Responsible for the development of individualized care plans for high and moderate stratified members in the Medicaid, Medicare, and Whole Health markets.
- Possesses clinical knowledge, understands best practices and continuous learning skills, reviews member records, and works in conjunction with primary care, community benefits, and other support opportunities to develop a long-term care plan to guide the member through their mental health care.
- Oversees the work of its assigned care support team and work with non-licensed support staff to meet standards of care and performance set by Member Market Leads and the Care Management Center of Operational Excellence (CoOE) Lead.
- Accountable for all Care Management activities for assigned high and moderate members with behavioral health conditions identified and assessed as requiring intensive interventions and oversight including multiple clinical, social, and community resources.
- Provides telephone triage, crisis intervention and prior authorizations as assigned for select members stratified as high and moderate member need.
- Conducts in depth health risk assessment and/or comprehensive needs assessment including, but not limited to, psycho-social, physical, medical, behavioral, environmental, and financial parameters.
- Develops, documents, implements, and communicates the patient-centered care plan, which provides appropriate resources to address social, physical, mental, emotional, spiritual and supportive needs.
- Educates providers, supporting staff, members and families regarding care management role and health strategies with a focus on member-focused approach to care.
- Serves as an accountable member of the care team to oversee appropriate rendering of services (e.g., during transitions in care or transition to home care, back up plans, community-based services).
- Oversees and effectively manages work assigned and conducted by assigned care support team, Implements, coordinates, and monitors strategies for members and families to improve health and quality of life outcomes.
- Acts as an advocate for members’ care needs by identifying and addressing gaps in care.
- Performs ongoing monitoring of members’ care plan and measures the effectiveness of interventions as identified; develops plans that strive to meet developed KPIs in accordance with the CM CoOE Lead and Member Market Leads.
- Assesses and reviews plan of care regularly to identify gaps in care, trends to improve health and quality of life outcomes.
- Works with members and the interdisciplinary care plan team to adjust plan of care as necessary.
- Facilitates a team approach, including all participants of the Interdisciplinary Care Plan team, Health Plan Medical Care Management where appropriate, to ensure appropriate interventions, cost effective delivery of quality care and services across the continuum.
Top 3 Must-Haves (Hard and/or Soft Skills):
- Utilization management experience for mental health and substance health
- Care management experience
- Proficient Typing skills
- Microsoft office experience
- MCG knowledge
Top 3 Nice-To-Haves (Hard and/or Soft Skills)
- DSM and ASM knowledge
Experience:
- 5 years of experience
Certification:
- LCSW – Licensed Clinical Social Worker, LMFT – Licensed Marriage and Family Therapist, LMSW – Licensed Master Social Worker, LPC – Licensed Professional Counselor, RN – Registered Nurse, State and/or Compact State Licensure
Education:
- Dependent on Certification–Associates: Nursing, Bachelors: Social Work, Masters: Social Work (Required)
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