Care Manager (Remote MD/ DC/ Northern VA)

Resp & Qualifications

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. This position is considered "remote" meaning that the incumbents generally works outside of a CareFirst location at their Primary Residence (or at a CareFirst location for meetings and/or training as needed).

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 member’s 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 member’s 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 and Certifications Required:

• RN  - Registered Nurse - State Licensure And/or Compact State Licensure.
• CCM/ACM or other RN Board Certified certification in case management (Must be qualified to complete exam and obtain certification within one year of hire).

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.

Knowledge, Skills and Abilities (KSAs)

• Incumbent must have an advanced knowledge of clinical standards of care and disease processes.
• Must have the ability to produce accurate and comprehensive work products with minimal direction.
• Must be able to triage immediate member health and safety risks.
• Must have a 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).
• Must have excellent verbal and written communication skills, along with the telephonic and keyboarding skills necessary to assess, coordinate and document services for members.
• Must be proficient in the knowledge of available community resources and programs and Proficient in the use of web-based technology and Microsoft Office applications such as Word, Excel and PowerPoint.
• Must be able to provide excellent internal and external customer service.
• Must be able to effectively work in a fast-paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long
• periods of time. 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.

Department

Department: Case Management 

Equal Employment Opportunity

CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer.  It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

Hire Range Disclaimer

Actual salary will be based on relevant job experience and work history.

Where To Apply

Please visit our website to apply: www.carefirst.com/careers

Federal Disc/Physical Demand

Note:  The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.

PHYSICAL DEMANDS:

The associate is primarily seated while performing the duties of the position.  Occasional walking or standing is required.  The hands are regularly used to write, type, key and handle or feel small controls and objects.  The associate must frequently talk and hear. 

Sponsorship in US

Must be eligible to work in the U.S. without Sponsorship

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