Case Manager, RN (Multiple Openings!)

company•City of Utica, NY

8d•$62,400 - $117,622

About The Position

Conducts case management program activities in accordance with departmental and corporate policies and applicable NYS Department of Health, CMS, Federal Employee Program, and NCQA standards. Uses a systematic approach to identify eligible members and assess opportunities to educate, support, coach, coordinate care, and review treatment options in collaboration with providers and community resources. Participates in a cross-functional, multidisciplinary team to implement member-centered interventions that support optimal, cost-effective health outcomes. Collaborates with the interdisciplinary care team to develop comprehensive care plans addressing member needs and health goals and mitigating healthcare cost drivers. The posting describes three classification levels with progressively broader responsibility, independence, complexity, leadership, and subject-matter expertise.

Requirements

Associate degree required; bachelor's degree preferred.
Active New York State licensure as a Registered Nurse, Registered Dietitian, or Physical Therapist required.
At least three years of clinical experience required.
Proficiency with the Microsoft Office Suite.
Strong written and verbal communication skills.
Ability to multitask, balance priorities, and work independently on a daily basis.
Ability to deliver efficient, effective, and seamless care to members.
For Federal Employee Program incumbents, Case Management Certification is required within two years of hire or moving into the role supporting the FEP line of business.
For Hospital to Home program incumbents only: an active NYS RN license with three years of behavioral health experience, or LMSW, LCSW, or LMHC qualification is required.
Level II: At least two years in a case management position; ability to escalate matters to management as necessary; proficiency with related technology and documentation; and consistent achievement of performance metrics.
Level III: At least five years in a current case management position or similar subject-matter-expert role; broad understanding of multiple functional areas such as Utilization Management and Case Management and their supporting systems; expertise handling complex assignments and highly visible issues; ability to lead new-staff training; and demonstrated presentation skills.

Nice To Haves

Case Management experience.
Experience interpreting managed care benefit plans and strong knowledge of Medicare and Medicaid government program contracts and benefits.
Level II: Case Management Certification.

Responsibilities

Manage physical health member clinical management programs at Level I and all member clinical condition management programs at Level II and above.
Follow applicable case management, regulatory, accreditation, licensure, certification, scope-of-practice, confidentiality, and information-management requirements.
Implement the case management process, including identification, case opening, assessment, education and support, care planning, interventions, outcome measurement, reassessment, case closure, and case reviews.
Screen referred or identified members and use case management criteria and clinical judgment to determine eligibility for services.
Initiate case management and open cases promptly; use motivational interviewing to explain case management information and support members in reaching their health goals.
Collaborate with members, caregivers, physicians, and other providers to assess needs, develop interdisciplinary care plans, coordinate services, evaluate effectiveness, and modify plans as needed.
Assess member and caregiver knowledge of illness and provide appropriate education to address knowledge gaps.
Work with members and caregivers to establish objectives, goals, and actions that address needs and barriers to achieving health goals.
Provide members with resources and assistance across the continuum of care; maintain information about community resources and act as a liaison between providers and those resources.
Coordinate with interdisciplinary teams, including Utilization Management, Quality, Behavioral Health, Pharmacy, Registered Dietitians, Respiratory Therapists, and other Case Managers.
Promote health plan programs, preventive health, web-based self-management tools, and digital health programs and applications.
Maintain continuing education and participate in value-based payment program work when applicable.
Support the company's mission, values, code of conduct, and member privacy policies; maintain regular and reliable attendance and perform other assigned duties.
At Level I, may participate in orienting new staff and work with internal and external stakeholders on value-based payment programs.
At Level II, suggest and participate in process improvements, mentor junior staff, meet performance and productivity metrics, work independently on more complex or larger caseloads, and serve as a positive role model.
At Level III, identify and evaluate process improvements, assist with policies and procedures, develop performance-improvement guidelines, handle escalations as a subject-matter expert, and mentor and guide clinical staff.
At Level III, provide backup for the Supervisor or Manager, assist with staff orientation and training, liaise with other organizational departments, and help ensure regulatory requirements are met, including through internal auditing.
At Level III, oversee case management functions relating to quality, productivity, utilization performance, and staff educational needs.