Case Manager, RN (Multiple Openings!)

Univera Healthcare•Rochester, NY

About The Position

The Case Manager 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. The role identifies members who may benefit from case management, assesses their needs, and provides education, support, coaching, care coordination, and review of treatment options in collaboration with providers and community resources. The Case Manager participates in a multidisciplinary team to develop comprehensive, member-centered care plans that address health goals and needs while supporting optimal, cost-effective outcomes. Responsibilities vary by classification level. Level I manages physical health cases and carries out the case management process, including screening, case opening, assessment, education, care planning, intervention, reassessment, case closure, and case review. Level II also handles all member clinical condition management programs, works more independently on complex assignments or larger caseloads, contributes to process improvements, and mentors junior staff. Level III provides subject-matter expertise, supports escalations and staff development, helps maintain processes and documentation, and may back up the Supervisor/Manager in operational and regulatory responsibilities. The position requires an associate degree and an active New York State license as an RN, Registered Dietitian, or Physical Therapist, along with at least three years of clinical experience. A bachelor’s degree and case management experience are preferred for all levels. Higher classification levels have additional case management experience and certification requirements. The job may involve travel, long hours working on a computer, and flexible hours to accommodate member discussions.

Requirements

Associate degree required.
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.
For incumbents supporting the Federal Employee Program line of business, Case Management Certification is required within two years of hire or moving into the role.
For Hospital to Home program incumbents only: active NYS RN license with three years of behavioral health experience, or LMSW, LCSW, or LMHC qualification required.
Level II: At least two years in a case management position; ability to escalate matters to management as needed; proficiency in 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; Case Management Certification; broad understanding of multiple areas such as UM and CM and their supporting systems; expertise handling complex assignments and challenging, high-visibility issues; ability to lead new-staff training; and demonstrated presentation skills.

Nice To Haves

Bachelor’s degree.
Case management experience.
Experience interpreting managed care benefit plans.
Strong knowledge of Medicare and Medicaid government program contracts and benefits.
Level II: Case Management Certification.

Responsibilities

Identify members who meet program criteria through data analysis or internal and external referrals, and determine their appropriateness for case management.
Initiate and manage cases in accordance with program descriptions, policies, procedures, guidelines, and applicable regulatory and accreditation standards.
Conduct member assessments, provide education and support, develop care plans, coordinate interventions, reassess outcomes, and close or review cases as appropriate.
Use motivational interviewing to communicate case management information and support members in achieving their health goals.
Collaborate with members, caregivers, physicians, healthcare providers, interdisciplinary care teams, and community resources to assess needs and coordinate services.
Develop member-centered objectives, goals, and actions that address health needs and barriers to care.
Evaluate the effectiveness of services and revise care plans as needed.
Maintain current information about community resources and act as a liaison between providers and those resources.
Coordinate with other health plan functions and clinical disciplines, 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 confidentiality and comply with corporate privacy, information management, licensure, certification, scope-of-practice, and regulatory requirements.
Maintain professional knowledge and meet continuing education requirements.
For Level II, handle all member clinical condition management programs, manage complex assignments or larger caseloads, suggest process improvements, mentor junior staff, and meet or exceed performance metrics.
For Level III, identify and evaluate process improvements, assist with policies and documentation, serve as an expert resource for escalations, mentor and guide clinical staff, and provide backup for the Supervisor/Manager.
At Level III, support staff orientation and training, help staff engage members in care, liaise on activities involving internal departments and stakeholders, and help ensure regulatory requirements are met.
Maintain regular and reliable attendance and perform other functions as assigned by management.