Care Management Specialist

GENERAL DESCRIPTION: Carries out nursing functions in performing care management process, organizational determinations, and transitional care, including, but not limited to, health assessments, biopsychosocial needs assessment, and barriers for policyholders with medical conditions to develop a comprehensive and customized care plan. Effectively coordinates the services necessary to maintain policyholders’ optimal level of health and facilitate access to services according to established requirements and timelines. Regular Exempt GENERAL DESCRIPTION: Carries out nursing functions in performing care management process, organizational determinations, and transitional care, including, but not limited to, health assessments, biopsychosocial needs assessment, and barriers for policyholders with medical conditions to develop a comprehensive and customized care plan. Effectively coordinates the services necessary to maintain policyholders’ optimal level of health and facilitate access to services according to established requirements and timelines. ESSENTIAL FUNCTIONS: Evaluates the criteria for admission to Complex Care Management Programs and Initiatives. Evaluates the policyholder’s condition to identify individual needs through a Health Risk Assessment. Establishes a comprehensive and individualized care plan with specific goals for each policyholder enrolled in the Care Management program using their judgment and the clinical guidelines adopted by the Company. Proactively identifies problems and barriers that may affect the policyholder’s care, establishing achievable goals and short- or long-term case management strategies and interventions. Guides the patient and family during the phase of acceptance and adaptation to chronic medical conditions that may result from them and provides appropriate follow-up. Documents the progress of the policyholder’s condition and all actions taken using the electronic app for documentation within the care plan and the electronic file, according to the policies and procedures established in the unit. Keeps effective communication about the policyholder’s condition and treatment with the physician, the service provider, and even the policyholder to evaluate their progress, guarantee integration in physical and mental health care, promote the policyholder’s self-care, and clarify any situation related to the clinical services they receive. Evaluates the effectiveness of the policyholder’s treatment. Takes part in case discussions with Providers whenever required to reevaluate the care plan and coordination of services needed. Coordinates with other departments the necessary referrals to cover the clinical and social needs applicable to the policyholder. Actively participates in meetings with the interdisciplinary team to discuss care options and treatment recommendations. Makes summaries of the cases worked and interventions, as requested. Performs the Organizational Determinations and Transitional Care process according to the regulatory agency’s established requirements and timelines for each line of business, following the MOC, Operational Guidelines, and Policies and Procedures. Complies with the Initiatives and Special Projects aimed at achieving the Stars, compliance with the Model of Care, and HEDIS measures. Performs monthly production of assigned cases as established in the unit. Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices. May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document. MINIMUM QUALIFICATIONS: Education and Experience: Bachelor’s degree in Nursing Sciences. At least two (2) or more years of experience in the direct care of patients with chronic health conditions. Previous experience working in a clinical area, preferably in the Health Insurance Industry, is desired. Certifications / Licenses: A valid Nurse & Association Nursing Professionals of Puerto Rico license and registration are required. Other: Skills in handling computer systems, such as MS Office, among others. Languages: Spanish – Intermediate (comprehensive, writing and verbal) English – Intermediate (comprehensive, writing and verbal) “We are an Equal Employment Opportunity Employer and take Aff….” #J-18808-Ljbffr MCS Puerto Rico