Care Manager II

Role Overview: The Care Manager 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 care plan 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:

• Fully remote position; candidates must reside in Michigan
• Must be willing to drive a personal vehicle for work-related events/meetings.
• Reliable high-speed internet is required to support daily job responsibilities, with a minimum bandwidth of 50 Mbps download and 5 Mbps upload.
• Associates residing in states where reimbursement is required by law, regulation, or contract may be eligible for internet reimbursement.

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:

• Associates Degree in Nursing required
• Bachelor's Degree in Nursing is preferred
• Current and unrestricted licensed Registered Nurse (RN) in Michigan is required.
• 2 to 3 years of experience in Labor and Delivery clinical experience required.
• 3 to 5 years of Case Management experience preferred.
• Certified Case Manager (CCM) is preferred but not required.

Licensure:

• Current and unrestricted RN in Michigan licensure is required.
• Valid driver's license and car insurance

Skills & Abilities:

• Strong knowledge of care management, care coordination, case management, and population health principles.
• Ability to perform comprehensive member assessments and develop effective care plans.
• Knowledge of social determinants of health and community-based resources.
• Strong clinical judgment and critical thinking skills.
• Ability to prioritize, organize, and manage multiple cases simultaneously.
• Excellent time management and follow-through skills.
• Strong communication and relationship-building skills with members, caregivers, providers, and community partners.
• Ability to work independently while collaborating effectively within a multidisciplinary team.
• Strong documentation and navigation skills for care management systems.
• Proficiency with electronic medical records (EMR), care management platforms, and Microsoft Office applications.
• Flexible, adaptable, and comfortable working in a dynamic and evolving healthcare environment.