Care Manager II

Role Overview: The Care Manager II is responsible for managing and coordinating care, services, and social determinants of health for medically fragile members with acute, chronic, medically complex, and/or behavioral health conditions, as well as other health needs. Serves as the primary point of contact for the care team, including members, caregivers, physicians, and community support, to guide members toward their optimal level of health. Utilizes strong assessment and communication skills, critical thinking, and clinical knowledge to identify issues, gaps in care, and barriers to care. Develops a plan of care through shared decision-making with the member/caregiver and in collaboration with providers and other care team members to improve the member's health status and compliance with treatment plans, as well as promote self-management.

Work Arrangement:

• Remote - Associate must reside in the state of Michigan (MI).

Responsibilities:

• Support members during transitions of care through assessment, coordination of care, education on the discharge plan of care, referrals, and evaluation of the plan''s effectiveness.
• Review the medication list, educate members on pharmacy needs, and counsel on side effects and mitigation strategies for specific treatment protocols.
• Evaluate, monitor, and update the care plan through regularly scheduled follow-up contacts based on the member/caregiver''s progress, needs, and preferences.
• Establishes points of contact to collaborate with identified community, medical, and/or behavioral health teams.
• Where applicable, maintain timely, complete, and accurate documentation of member interactions in the electronic care management platforms.
• Monitor appropriate utilization, coordinate services with other payer sources, make appropriate referrals, and identify and escalate quality-of-care issues.
• Develop a working knowledge of the electronic care management platforms, care management programs, policies, standard operating procedures, workflows, member insurance products and benefits, community resources and programs, and applicable regulatory, state, and National Committee for Quality Assurance (NCQA) requirements.
• May identify cases to be presented at care management rounds and follow up with providers on recommendations to achieve optimal outcomes for members.
• For education and/or assessment, face-to-face visits may be required at the member's residence, provider's office, hospitals, other acute locations, or community locations.

Education & Experience:

• Associate Degree in Nursing required.
• Bachelor of Science in Nursing preferred.
• Current, active, and unrestricted Registered Nurse (RN) licensure.
• 3 or more years of clinical experience at the bedside working with medically fragile patients in an acute care, home care, or special needs clinic.
• 3 or more years of case management experience, preferably by telephone, within a managed care organization, is desired.
• Demonstrated proficiency working within Office 365, including MS Office (Excel, Word, Outlook) and electronic medical record and documentation programs.

Licensure:

• Current, active, and unrestricted Registered Nurse licensure.
• Eligible to sit for the Case Management certification after 12 months of employment. Must obtain this certification within 24 months of employment.
• Valid driver''s license and car insurance.
• Must be willing to drive a personal vehicle for work-related events/meetings.

Skills & Abilities:

• Support a positive workplace environment, collaborate, and share clinical knowledge and skills to support our culturally and demographically diverse member population.