RN Care Manager

Capital Blue Cross•Harrisburg, PA

15h•$29 - $54

About The Position

The Care Manager coordinates services for members who meet established criteria, emphasizing education, self-management, quality care, and cost-effective outcomes. Using a collaborative process, the Care Manager assesses member needs, reviews service and resource options, develops and implements individualized plans of care, coordinates resources, monitors progress, evaluates member status, and discharges members when appropriate. The role includes fully documenting the care management process and its outcomes. The Care Manager addresses medical, psychosocial, clinical, and behavioral health needs, including mental health and substance use disorder needs. The role provides counseling and referrals to community, local, and state programs, and collaborates with caregivers, providers, community agencies, behavioral health resources, and others to coordinate care and support members’ optimal health status. The Care Manager manages and oversees a caseload of moderate- to high-risk members with complex medical, behavioral, and psychosocial needs.

Requirements

Registered Nurse with active licensure in the home state; additional state licensure as needed or required to meet customer needs.
At least three years of recent or related experience.
Obtain Certified Case Management certification within two years of employment.
Strong communication skills and the ability to interact positively with customers, peers, leadership, family members, caregivers, visitors, contracted agencies and personnel, and the general public.
Superior clinical process, critical-thinking, and problem-solving skills, including the ability to handle critical situations.
Excellent written and oral communication, listening, and organizational skills.
Ability to use a computer system while conversing by telephone.
Strong customer service skills, including tact and diplomacy in person and by telephone with internal and external customers.
Ability to prioritize workload and assignments and complete duties accurately, in detail, and on time.
Ability to work autonomously and as part of an interdisciplinary team.
Sound judgment that affirms the rights and responsibilities of members, families, healthcare professionals, and healthcare organizations.
Ability to operate a personal computer and proficiency with Microsoft Office products.
Knowledge of NCQA standards for Population Health Management for health plan accreditation, DMAA standards for disease management, CMSA Standards of Practice for Case Management, Act 68, CMS, and ERISA.
Knowledge of evidence-based guidelines for chronic conditions and care management.
Knowledge of clinical and managed care principles and operations.
Knowledge of current and emerging medical treatment modalities and best-practice guidelines, with the ability to analyze and interpret medical and benefit coverage interrelationships.
Knowledge of adult learning principles, motivational interviewing, and intrinsic coaching techniques.
Ability to travel to provider, facility, employer group, and/or member locations using a personal vehicle, if appropriate.

Nice To Haves

Care management, home health, medical/surgical behavioral health, and/or critical care experience is preferred.
Health plan experience is preferred.
Additional experience related to specialized positions such as Oncology, Transplant, Maternity, or Behavioral Health will also be considered.
Experience in health coaching and motivational interviewing techniques is preferred.

Responsibilities

Serve as a liaison among participants, families and significant others, behavioral and medical physicians, and other members of the treatment team.
Develop prioritized goals and health actions that support participant-directed care decisions, improved health, and self-reliance.
Advocate for members and families by coordinating care and helping them navigate resources to reduce barriers and meet healthcare needs.
Analyze and evaluate referrals for potential enrollment in Care Management Programs using established criteria.
Conduct assessments to inform participant-centered plans of care and determine acuity, functional status, psychosocial status, and barriers.
Obtain consent forms for candidates accepted into Care Management Programs.
Discharge members from Care Management Programs when established discharge criteria are met.
Conduct and document care management activities in accordance with departmental policies and procedures, and comply with Clinical Management and corporate policies and procedures.
Build relationships with members and families and implement interventions to advance improved knowledge, self-management, and long-term care outcomes, including stabilization.
Identify and report quality-of-care issues in accordance with departmental policies and procedures.
Maintain member confidentiality.
Attend required company and departmental meetings and training sessions.