Care Manager

ROLE AND RESPONSIBILITIES

The role of the care management nurse is to manage the Managed Medicare product for assigned Provider Network partnering with the Accountable Care Organization (ACO).  This includes: facilitating provider communications, program implementation and continual training; data review, system utilization and complex case management. The Care Manager serves as a liaison between providers and the managed care team to promote superior customer service and seamless program coordination. The Care Manager strives to promote self-managed care and the use of healthcare resources in the most cost-effective way possible primarily focusing on a specific population. The individual in this position has overall responsibility for overseeing the clinical plan of care to conform to evidence-based practice and regulatory requirements.

CORE FUNCTIONS

  • Provider Group management - overall management of assigned Provider Groups; fostering an environment of strong positive relationships and performance

  • Proactively identify Provider Group’s needs, resolving and communicating concerns or complaints regarding ACO Managed Care programs to maintain Provider Group satisfaction

  • Subject matter expert in Managed Medicare Star Ratings, Risk Adjustment and overall framework of the Managed Medicare product

  • Identify opportunities for improved processes and Provider Group participation in established ACO Managed Care programs

  • Identifies members appropriate for Care Management by use of targeted chronic conditions, level of care, and recognition of member’s disease specific and preventative measures, knowledge base or deficits in monitoring health, wellness and chronic conditions. Reviews and analyzes clinical indicators and whether there is any ‘gap’ in compliance that will result in member contact

  • Develops and implements a plan of care

  • Monitors the plan of care to determine if the goals are being met on an ongoing basis to evaluate for needed changes and updates the plan of care accordingly. Closes the plan of care when complete

  • Conducts outbound calls to members to complete telephonic assessments and provide interventions and education for the management of their health, wellness and chronic conditions

  • Collaborates with the Provider or their designee to address the plan of care from an integrated approach

  • Identifies and reports quality of care issues to the Medical Director and the VP of Medical Management

  • Communicates and collaborates with Medical and Nursing staff.  Promotes the mission, philosophy, goals, and policies of the company through staff education

  • Provides clinical oversight of the care plan and care coordination process implemented by Care Coordinator Assistants

  • Maintain personal professional development

  • Performs other duties as assigned

QUALIFICATIONS AND EDUCATION REQUIREMENTS

  • Must possess a current and active nursing license to practice in the state assigned or maintain a compact license

  • RN license preferred

  • CCM or CPC highly desirable

  • 3 years of various clinical experiences

  • Ability to utilize nursing skills to understand and coordinate care of those members that are significantly physically compromised by their illness and/or disability

  • Accountable and autonomous

  • Ability to handle multiple demands of diverse workload and prioritizes critical issues

  • Ability to effectively communicate verbally and in writing

  • Ability to build effective collegial relationships

  • Ability to influence and effect change

  • Ability to analyze and think critically

  • Possesses current knowledge of disease pathophysiology, psychosocial issues, and treatment

  • Good time management skills

  • Positive, service-oriented attitude. High level of integrity

  • Computer literate

  • Must maintain valid driver’s license and vehicle


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