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CommuniCare Advantage · 1 week ago

Health Plan Care Manager

Corydon, IN

Full-time

Onsite

Mid, Senior Level

3+ years exp

CommuniCare Advantage is dedicated to providing high-quality healthcare services. The Care Manager will coordinate member care, develop actionable care plans, and ensure effective communication to deliver optimal healthcare services to members in an institutional setting within a special needs plan (ISNP).

Elder CareHealth CareHealth InsuranceInsurance

Hiring Manager

Lizzy Hull

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: Performs 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: Formulates and implements 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: Collaborates 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

Qualification

Licensed master’s in social workLicensed Registered Nurse (RN)Certified Case Management (CCM)Case/Care Management experienceValue-based careCare coordination expertiseCritical thinkingCommunication skillsOrganizational skillsInterpersonal skills

Required

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, documentation. Documentation integrity is taken quite seriously and will be audited on a frequent basis

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

Must be willing to be present at assigned facilities to attend care conferences, conduct Model of Care activities, have direct oversight and be accountable for the outcomes of assigned membership

Occasional travel outside of servicing area, less than 5%

May work beyond normal working hours, on weekends and holidays, when necessary

Ability to work in an environment of ambiguity and constant change with limited resources at times