Health Plan Care Manager - Remote

Martin’s Point Health Care•Portland, ME

2d•$86,926 - $107,379•Remote

About The Position

The Care Manager provides comprehensive, person-centered, care management (CM) interventions for members and families enrolled in Care Management. Effectively engages, assesses, monitors, educates, coordinates, and provides interventions for members and families to improve the quality of care and member health outcomes. This role reduces unnecessary health care utilization. Collaborates with physicians, hospitals, skilled nursing facilities, home health providers and community services to advocate for member-centered goals and needs, to promote better health, and to prevent unnecessary hospital utilization.

Requirements

Bachelor’s degree in nursing required
5 years of current clinical experience, ideally in one or more of the following areas or specialty practice: medical-surgical, home care, hospice, community health, rehabilitation, long term care, cardiovascular, diabetes, renal, or pulmonary diseases, oncology, and geriatrics.
Experience in a managed care, home health or hospital environment
Unrestricted state licensed registered nurse license required
Knowledge of Scope of Nursing Practice in states where licensed
Demonstrates an understanding of and alignment with Martin’s Point Values.
Current clinical knowledge in chronic diseases, heart disease, COPD, diabetes, renal disease and other co-morbidities.
Uses sound judgment to identify subtle changes and anticipates and intervenes to prevent problems and complications.
Must be a self-initiator with high energy/productivity and a strong work ethic
Proven history as a team player
Flexibility and adaptability in managing multiple priorities, changing schedule
Excellent communication skills (written and verbal)
Excellent organizational and time management skills

Nice To Haves

MSN preferred
CCM certification preferred

Responsibilities

Completes comprehensive advanced level nursing assessments for new and existing members, that include focused physical examinations, with attention to complex care and comorbidities.
Incorporates a sophisticated knowledge of evidence-based, best practice standards of care for chronically ill members.
Provides care management and care coordination according to the Current Standards of Practice for Case Managers established by the Care Management Society of America (CMSA) and the established definitions of care management and care coordination published by CMSA, NCQA, TRICARE, and CMS.
Applies evidence-based criteria, e.g., CMS, and HEDIS quality measures, for care management processes and interventions.
Manages care within the benefits structures per line of business and performs functions within compliance, contractual and accreditation regulations, e.g., Department of Defense (DOD), CMS, URAC, and NCQA
Ensures initial member assessments, screenings, care transition assessments, encounters and follow-up are timely, complete, accurate, and according to established Care Management (CM) standards and protocols; and are documented in the case management medical record.
Collaborates with the members’ primary care provider, specialists, MPHC medical directors and community service agencies, to address concerns from a member-centered perspective.
Engages, assesses, and provides interventions and support to members, their families and caregivers to address medical, health, social, psychological, environmental and lifestyle issues; with the goal of improving health and preventing unnecessary hospital utilization.
Documents all assessments, encounters, and other CBN activities in the case management medical record in a timely fashion.
Ensures all written communication and member records and forms (both electronic and on paper), are complete, clear, well organized, legible, and professional (including proper grammar, spelling and include only approved abbreviations) and comply with MPHC CM standards.
Demonstrates extraordinary teamwork skills that include flexibility, adaptability, and accountability, to meet the dynamic needs of the members and of the team and program, in a fast-paced learning environment.
Develops and present case studies, participate in clinical rounds, in-services, and staff education and training.
Demonstrates respect and excellent customer-service skills with all contacts. All aspects of conduct are respectful, professional, and ethical.
Assists with process improvements and supports quality initiatives to enhance efficiency and outcomes.
Provides support with projects and completes additional assignments as required.