Health Plan Care Manager (RN or LSW)

Health Plan Care Manager

CommuniCare Advantage is currently recruiting Health Plan Care Managers in West Virginia for our Medicare Advantage plan. Candidates must be licensed as a Registered Nurse or as a Social Worker in the state of employment.

Purpose / Belief Statement: The position of Care Manager is part of Healthcare Services and reports to the Director of Care Coordination who reports to the VP of Healthcare Services and Quality Operations. This position will have strong working relationships with the Chief Medical Officer and other key contributors across the enterprise. The Care Manager will be responsible for coordinating member-care, developing actionable care plans, communicating effectively, and ensuring high-quality healthcare services are delivered to members in an institutional setting within a special needs plan (ISNP).

Job Duties & Responsibilities

• Care Coordination: Oversee and coordinate the care of assigned ISNP members, ensuring they receive timely and appropriate care as dictated by the SNP Model of Care. Average caseload of 75-100 ISNP members with the ability to cross cover other clinicians as deemed necessary.
• Member Assessment: Perform initial, annual, transition of care (TOC) and change in condition health risk assessments (HRA) for ISNP care managed caseload. Assessments may include, but are not limited to additional assessments such as PHQ-9, MMSE, Medication Reconciliation, Advanced Directives, etc. The health risk assessment includes a systematic and pertinent collection of data about the health status of the member and requires the member/representative input. Accurate assessment determines cadence of visits/needs and frequency/intensity of care management oversight. Risk stratification is dictated by the specifics within the Model of Care and evaluated with each member interaction.
• Care Planning: Formulate and implement a member centric holistic care plan that addresses identified needs by assessing the member/representative/family needs, issues, resources and care goals; determining and educating on the choices available to the individual member. Establish a care plan that is mutually agreed upon by the interdisciplinary care team and the member/representative/family. Care plans will be established and maintained utilizing the SMART framework (Specific, Measurable, Achievable, Relevant and Time-bound) and communicated to all members of the interdisciplinary care team.
• Collaboration: Collaborate with the interdisciplinary team (ICT) which may include Medical Director, PCP, nurse practitioners/physician assistants, pharmacy, dietary, social workers, other clinical and non-clinical disciplines, facility staff, member representatives and family to establish, revise and continuously evaluate the member centric care plan and conduct documented interdisciplinary care team meetings to be able to work proactively rather than reactively. Care Manager will work closely with Utilization Management, Compliance and Quality to adhere to the Model of Care and ensure quality assurance, cost efficiency and member safety/satisfaction.
• Member Education: Provide education to members and their families about managing chronic conditions and promotion of self-management strategies.
• Documentation: Maintain accurate and timely documentation of member care activities and any interaction related to the member in compliance with healthcare regulations.

Qualifications & Experience Requirements

• Licensed master's in social work or licensed Registered Nurse (RN) with a minimum of a bachelor's degree
• Clinicians must be clinically licensed in the State they are managing members or have compact licensure
• Certified Case Management (CCM) certification or willing to obtain within 1 year of hire (company sponsored)
• Active drivers license as this is NOT a remote role and must have reliable transportation to enable face to face visit to members in facilities
• Minimum of 3-5 years in Case/Care Management preferred and/or 5+ years of direct patient care
• Knowledge of value-based care, fee for service and Medicare Advantage/Dual (Medicare/Medicaid), NCQA, HEDIS and basic Utilization Management functions
• Expertise in care coordination for geriatric and high-risk populations
• Ability and experience utilizing a variety of applications and databases to fulfill care management requirements, and documentation. Documentation integrity is taken quite seriously and will be audited on a frequent basis.

Knowledge / Skills / Abilities

• Critical thinking is key. Act before reacting
• BE PRESENT both physically and for our members. Listen with compassion and learn to "walk in one's shoes"
• Must have integrity, be honest and have a strong ethical compass.
• Nimble, establish boundaries and foster emotional intelligence
• Strong planning and organizational and time management skills with the ability to work independently
• Must be excited by the opportunity to work within an integrated delivery system
• Strong communication skills and the ability to work effectively with people coming from diverse cultural and professional perspectives
• Subject matter expert in care management
• Excellent interpersonal, written, and organizational skills required