PURPOSE:

Under minimal supervision, the Care Manager researches and analyzes a member's medical and behavioral health needs and healthcare cost drivers. The Care Manager works closely with members and the interdisciplinary care team to ensure members have an effective plan of care and positive member experience that leads to optimal health and cost-effective outcomes.
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This position will support the Maryland government programs division, specifically the Medicare Advantage line of business. The Care Manager helps members, families, and caregivers access the health care delivery system through outreach, education, follow-up, coordination support, and resources. You will work with other members of the interdisciplinary care team to coordinate services, decrease utilization, and ensure optimal health outcomes.

We are looking for an experienced professional to work remotely within the greater Baltimore/Washington metropolitan area. While this position is remote, the incumbent will be expected to come into a CareFirst location periodically for meetings, trainings and/or other business-related activities.

In addition, the Care Manager participates in community-based events, representing the face of CareFirst and its efforts to promote the health and wellness of our members and their communities.

ESSENTIAL FUNCTIONS:

• Identifies members with acute/complex medical and/or behavioral health conditions. Engages onsite and/or telephonically with member, family and providers to develop a comprehensive plan of care to address the members needs at various stages along the care continuum. Identifies relevant CareFirst and community resources and facilitates program, network, and community referrals.
• Collaborates with member and the interdisciplinary care team to develop a comprehensive plan of care to identify key strategic interventions to address members medical, behavioral and/or social determinant of health needs. Engage members and providers to review and clarify treatment plans ensuring alignment with medical benefits and policies to facilitate care between settings. Monitors, evaluates, and updates plan of care over time focused on member's stabilization and ability to self-manage. Ensures member data is documented according to CareFirst application protocol and regulatory standards.

QUALIFICATIONS:

Education Level: High School Diploma or GED.

Licenses/Certifications Upon Hire Required:

• RN - Registered Nurse - State Licensure And/or Compact State Licensure RN- Registered Nurse in MD, VA or Washington, DC.

Experience: 5 years clinically related experience working in Care Management, Discharge Coordination, Home Health, Utilization Review, Disease Management or other direct patient care experience.

Preferred Qualifications:

• Bachelors degree in nursing.
• CCM/ACM or other RN Board Certified certification in case management.
• Previous experience with Medicare and/or Medicare Advantage patient populations with multiple co-morbidities, complex needs, social determinants of health and/or barriers to care.
• Bilingual - fluent in Spanish.
• Skilled in typing and working within various web-based platforms.

Knowledge, Skills and Abilities (KSAs)

• Knowledge of clinical standards of care and disease processes.
• Ability to produce accurate and comprehensive work products with minimal direction.
• Ability to triage immediate member health and safety risks.
• Basic understanding of the strategic and financial goals of a health care system or payor organization, as well as health plan or health insurance operations (e.g. networks, eligibility, benefits).
• Excellent verbal and written communication skills, along with the telephonic and keyboarding skills necessary to assess, coordinate and document services for members.
• Knowledgeable of available community resources and programs.
• Proficient in the use of web-based technology and Microsoft Office applications such as Word, Excel and PowerPoint.
• Ability to provide excellent internal and external customer service.
• Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.