Care Manager
We are transforming healthcare to be value-driven, creating a seamless, consumer-centric care experience that maximizes value for all.
We believe that all health consumers are entitled to high quality, coordinated healthcare. We uniquely align the interests of health consumers, providers, and payors to make high-quality healthcare accessible and affordable to all populations across the ACA Marketplace, Medicare, and Medicaid.
JOB SUMMARY
The role of the Care Manager is to promote quality, cost-effective outcomes for a population by facilitating collaboration and coordination across settings, identifying member needs, planning for care, monitoring the efficacy of interventions, and advocating to ensure member’s receive services and resources required to meet desired health and social outcomes. The Care Manager is responsible for providing patient centered care across the care continuum.
This position will be based onsite at a medical center in the Miami area.
DUTIES & RESPONSIBILITIES
- Collect relevant clinical data to support the care planning process.
- Provide Care Plan support, intervention, and prioritization to transition members to optimal levels of health and self-management.
- Participate in interdisciplinary team meetings as required.
- Collaborate across providers and healthcare settings to ensure optimal quality outcomes for an assigned population.
- Provide transition of care interventions as required.
- Facilitate care coordination, self-management planning, discharge planning, and health education for an assigned population.
- Facilitate linkage to appropriate community resources to address social determinants of health.
- Adjudicate referrals and apply evidence-based clinical criteria to coordinate member care needs across all care settings.
- Able to ensure member communication and notices are composed in a manner consistent with regulatory standards.
- Adheres to the Policies and Procedures set forth by the Quality Management Committee and performs all additional duties as assigned.
EDUCATION AND PROFESSIONAL EXPERIENCE
- Minimum associate's degree in nursing or bachelor's degree in social work or related field
- Minimum 2 years of experience in care management clinical functions.
- Working knowledge HEDIS measures and NCQA standards
- Active Florida License as a Licensed Vocational Nurse (LVN), RN, LCSW, LMFT is preferred
- Certification in Case Management (CCM) or Managed Care Nursing (CMCN) preferred.
PROFESSIONAL COMPETENCIES
- High level of critical thinking and problem-solving skills
- Strong work ethic and overall positive attitude
- Effective communication skills including verbal and written.
- Ability to manage time effectively, understand directions, and work independently in a fast-paced environment.
- Demonstrated flexibility, organization, and self-motivation.
- Highly adaptable to change.
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