Medicaid Special Programs Case Manager

Capital District Physicians' Health Plan, Inc.•Latham, NY

36d

About The Position

Grounded by a compelling mission, core values, and compassion for people, CDPHP and its family of companies offer a strong foundation for a rewarding career. Established in 1984, CDPHP is a physician-founded, member-focused, and community-based not-for-profit health plan that offers high-quality affordable health insurance to members throughout New York. The company values people, quality, innovation, and community, and its corporate culture supports those values wholeheartedly. CDPHP is committed to fostering a culture of belonging and takes a wholistic approach to diversity, equity, and inclusion. At CDPHP, the employees have a voice and are encouraged to make an impact at both the company and community levels through engagement and volunteer opportunities. CDPHP invests in employees who share these values and invites you to be a part of that experience. The Medicaid Special Programs Registered Nurse Case Manager is responsible and accountable for coordinating the care of CDPHP members who meet case management criteria across the continuum of care, ensuring and facilitating the achievement of quality, clinical and cost outcomes. In addition, the Medicaid Special Programs Registered Nurse Case Manager is responsible and accountable for coordinating requests for prior authorization received via the telephone line, fax machine and mail. The Medicaid Special Programs Case Manager typically works in the telephonic managed care setting but may be called on to work from a variety of other locations as needed, including, but not limited to, a primary care office or a community room affiliated with a community agency. Activities focus on patient education and coordination of care for CDPHP members with a chronic condition. The discrete activities include member outreach, care planning, motivational interviewing and acting as a key clinical liaison between the provider, member and CDPHP. The Case Manager will perform all functions by articulating and documenting in CDPHP applications and, when applicable, a practice's electronic medical record with a high level of accuracy. The Case Manager must combine strong clinical knowledge and critical thinking to coordinate and support a care plan that will monitor quality medical care for the member population serviced by CDPHP. Based on national standards for case management practice, the RN Case Manager will focus on empowering the member to support optimal wellness while advocating for the necessary medical services across the health care continuum. The RN Case Manager will demonstrate strengths in working independently as well as collaboratively within a team environment or with external stakeholders such as PCPs and office staff. Understanding of the department's/PCP office business objectives and outcome measures is important to the accountability of the Medicaid Special Programs RN Case Manager and the success of the member-focused Complex Case Management Programs.

Requirements

Registered Nurse with a current New York State license is required. BS in Nursing preferred. LPN plus one year of experience with CDPHP will be considered in lieu of RN.
Valid driver's license and driving record showing no restrictions that would impede ability to travel by automobile required.
Flexibility to travel to a variety of sites across CDPHP service area required.
A minimum of three (3) years clinical experience is required.
Experience with chronic condition management, particularly diabetes and heart disease is required.
Demonstrated ability to work with diverse population.
Demonstrated problem solving, communication (verbal & written) and organizational skills.
Demonstrated ability to influence others while motivating them to change.
Demonstrated ability to elicit required information, interact professionally with difficult callers and provider practitioners.
Ability to provide members with ongoing assistance and education regarding plan requirements.
Demonstrated ability to review health care delivery against established criteria required.
Ability to communicate effectively with members with varying levels of education, health literacy and understanding.
Demonstrated ability to interact with provider, members to positively impact the quality of patient care required.
Proven customer service skills.
Foster teamwork as an attitude and a skill.
Ability to manage multiple projects in conjunction with patient caseload.
Demonstrated PC skills experience is required.
Working knowledge of health, social service and funding resources, including community agencies and alternate care delivery systems is required.
Access to reliable transportation to all CDPHP service areas to deliver service to members during regular business hours, evenings and possibly weekends is required.
Ability to represent CDPHP in a professional and positive manner.

Nice To Haves

Spanish speaking preferred.
Previous experience working with Medicaid Long Term Care Programs preferred.
Minimum of two (2) years Utilization Management experience is preferred.
Experience with the New York State Universal Assessment System is preferred.
Case management experience and CCM certification preferred.
Familiarity with community resources and social service resources to assist patients with social needs preferred.
Experience in home care, medical office setting, or managed health plan preferred.
Ability to provide case management for complicated members with multiple co morbidities and chronic diseases.
Understanding of coding/claims processing is preferred.

Responsibilities

Coordinating the care of CDPHP members who meet case management criteria across the continuum of care, ensuring and facilitating the achievement of quality, clinical and cost outcomes.
Coordinating requests for prior authorization received via the telephone line, fax machine and mail.
Patient education and coordination of care for CDPHP members with a chronic condition.
Member outreach, care planning, motivational interviewing and acting as a key clinical liaison between the provider, member and CDPHP.
Performing all functions by articulating and documenting in CDPHP applications and, when applicable, a practice's electronic medical record with a high level of accuracy.
Combining strong clinical knowledge and critical thinking to coordinate and support a care plan that will monitor quality medical care for the member population serviced by CDPHP.
Focusing on empowering the member to support optimal wellness while advocating for the necessary medical services across the health care continuum.
Working independently as well as collaboratively within a team environment or with external stakeholders such as PCPs and office staff.

Benefits

CDPHP compensation packages go far beyond just salary. The company offers a comprehensive total rewards package that includes award-winning health care coverage, health care dollars, a generous paid time off allowance, employee assistance programs, flexible work environment, and much more.
Learn about all CDPHP employee benefits at https://www.cdphp.com/about-us/jobs/benefits.

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