Resp & Qualifications
The Care Manager supports the CM Manager and Director of Case Management for TANIF (Healthy Families) Medicaid or Special Needs, while ensuring that available resources are being used in a timely and cost-effective manner in order to obtain optimum value for both the enrollee and the reimbursement source. The Care Manager will adhere to the principle of the Quadruple Aim – improving enrollee experience, better outcomes, improved clinical experience, lower costs while pursuing health equities for our enrollees.
The Care Manager will take part and be fully engaged in the team direction, address problems and provide guidance to members of the team to ensure the team meets established performance metrics and performance guarantees. The Care Manager is part of an effective, efficient workforce to support all aspects of the Case Management department across the continuum of care settings and clinical programs and services for enrollees. This includes the planning, implementation, and refinement of case management programs and initiatives for medical management that support departmental and divisional goals. Depending on the specific business area, the Care Manager can support the role of Care Coordinators and Community Health Worker. The role works closely with the Supervisor and Senior Care Manager to develop and operationalize sustainable processes to support functional improvements for the organization.
The Care Managers are delegated to disease process as much as permitted – the following are the processes followed by case management but not limited to:
- Early Intervention
Under the general direction of the Supervisor and Manager of Case Management for the TANIF (Healthy Families) Medicaid population, the Care Manager’s accountabilities include, but are not limited to, the following (specific goals for Case Management Department are determined on an annual basis in accordance with directives from the executive board of CareFirst Community Health Plan Blue Cross Blue Shield):
- CASE MANAGEMENT PROCESS
- Identification/Risk Stratification:) Engages enrollees into the case management program (outreach and successful enrollment) using diagnostic cost grouper classification reports, which identify the relative risk score and illness burden. Identifying catastrophic health care users with significant health care costs in the High Intensity care needs.
- Assessment: Conducts and documents a comprehensive assessment of the enrollee’s health psych/social needs, including health literacy and deficits. Obtains verbal consent to initiate case management services. Gathers clinical, which includes past medical history, medications, physical/psychosocial factors, cultural influences, evaluation of health care barriers to include available support systems, available benefits, community resources, and treatment and medication compliance according to NCQA Case Management Accreditation.
- Planning: Proficient case management clinical knowledge and experience to coordinate integrated care-plan development involving the enrollee, family, Hospital Transition of Care (HTC) nurse, Care Coordination (CC) and Care Manager (RNCM), Primary Care Physician (PCP), specialists and other healthcare providers/vendors. Goals developed will be prioritized, action-oriented and time-specific to stabilize the complicated health care condition and meet NCQA standards of documentation for Case Management Accreditation
- Facilitation of Communication and Care Coordination: Executing the transition of care includes moving the enrollee from one healthcare practitioner and setting to another as their healthcare needs change. One key responsibility of the case manager is to minimize the fragmentation of care services and adverse outcomes. Completes a review of service request containing all appropriate information (clinical, medical policy, contact/complex benefit structure, FDA treatment, clinical trials and drugs) to allow the medical director to make a medical necessity determination. Identifies and provide educational and community resources, support groups, pharmacy program and financial assistance.
- Monitoring: Documentation will reflect the necessary communication with the enrollee, family, physicians, and other health care providers to ensure the enrollee’s progression in meeting the established care plan goals.
- Outcomes Management: Evaluate the extent to which the established goals in the plan of care have been achieved.
- APPLICATION PROFICIENCY
- Portal Data Base: Case management documentation is completed in the Care Connect system
- Claims: Assists in claims inquiries and resolution
- Legacy Systems (MHC, Care Connect and OSSE): Confirms enrollee eligibility and available benefits
- Care Planner Web: Authorization management; generates coverage and adverse decision correspondence using appropriate language to meet state, federal and all regulatory requirements
- Employer Group/Accreditation Audits: Participates in the preparation and on-site reviews (NCQA, OSR and DHCF)
- Knowledgeable of federal/state mandates as they apply to various plan contracts
- Documentation Audit: Responsible for completion of documentation review and peer to peer audit as assigned by management
- MCG Chronic Care Guidelines: Familiarity with and usage of for the purpose of discharge planning (and length of stay review for FEP Line of Business only)
- NCQA Compliance: Responsible for adherence to the NCQA Complex Case Management Standards and Health Plan Standards
- CMSA: Adheres to the CMSA Standards of Practice for Case Management
- HIPAA: Maintains confidentiality of patient information according to HIPAA and departmental policies.
- OTHER DUTIES AS ASSIGNED
- Assist in the training and re-training of RN Care Managers, Care Coordinators and Community Health Workers
- Complete task management
- Assist during staffing challenges
- Share in the duty of coverage at Wellness Center
To perform the job successfully, an individual should demonstrate the following competencies:
- Analytical | Experience working with statistical methodologies, analytical and statistical theories. Knowledge of applied use of data in health program monitoring and evaluation.
- Problem Solving - Identifies and resolves problems in a timely manner; Gathers and analyzes information skillfully; Develops alternative solutions; Works well in group problem solving situations.
- Project Management | Communicates changes and progress; Completes projects on time and budget.
- Technical Skills - Assesses own strengths and weaknesses; Pursues training and development opportunities; Strives to continuously build knowledge and skills; Shares expertise with others.
- Customer Service | Manages difficult or emotional customer situations; Responds promptly to customer needs; Solicits customer feedback to improve service; Responds to requests for service and assistance; Meets commitments.
- Interpersonal Skills | Solution oriented approach to conflict and challenges; Maintains confidentiality; Practices effective listening skills; Maintains professional demeanor; Remains open to others' ideas and tries new things.
- Oral Communication | Speaks clearly and persuasively in positive or negative situations; listens and gets clarification; Responds well to questions; Demonstrates group presentation skills; Actively participates in meetings.
- Written Communication | Writes clearly and informatively; Edits work for spelling and grammar; Varies writing style to meet needs; Able to read and interpret written information.
- Quality Management | Demonstrates accuracy and thoroughness. Applies quality assurance principles to data management activities.
- Diversity | Shows respect and sensitivity for cultural differences; Promotes a harassment-free environment and respects diversity.
- Ethics | Treats people with respect; Keeps commitments; Inspires the trust of others; Works with integrity and ethically; Upholds organizational values.
- Organizational Support | Understands organization's goals and values and role in achieving those goals; Follows policies and procedures; Completes administrative tasks correctly and on time.
- Strategic Thinking - Develops strategies to achieve organizational goals; Understands organization's strengths & weaknesses; Analyzes market and competition; Adapts strategy to changing conditions.
- Judgment | Displays willingness to make decisions; Includes appropriate people in decision-making process; makes timely and data-driven decisions.
- Motivation | Sets and achieves challenging goals; Demonstrates persistence and overcomes obstacles.
- Planning/Organizing - Prioritizes and plans work activities; Uses time efficiently; Plans for additional resources; Ability to multi-task.
- Professionalism Approaches others in a tactful manner; Reacts well under pressure; Treats others with respect and consideration regardless of their status or position; Accepts responsibility for own actions; Follows through on commitments.
- Quality Demonstrates accuracy and thoroughness; Looks for ways to improve and promote quality; Applies feedback to improve performance; Monitors own work to ensure quality.
- Safety and Security - Observes safety and security procedures; Reports potentially unsafe conditions.
- Adaptability | Adapts to changes in the work environment; Manages competing demands; Changes approach or method to best fit the situation; Able pivot work with frequent change, delays, or unexpected events.
- Attendance/Punctuality | Consistently at work and on time; Ensures work responsibilities are covered when absent; Arrives at meetings and appointments on time.
- Dependability | Follows instructions, responds to management direction; Takes responsibility for own actions; Keeps commitments; Commits to long hours of work when necessary to reach goals; Completes tasks on time or notifies appropriate person with an alternate plan.
- Initiative | Volunteers readily; Undertakes self-development activities; Seeks increased responsibilities; Looks for and takes advantage of opportunities; Asks for and offers help when needed.
- Registered Nurse in the District of Columbia in good standing
- Bachelor’s Degree in Nursing preferred
- Certified Case Management Certification preferred and must be obtained within 2 years from hire date
- Three to Five Years of experience in case management in homecare, hospice, or managed care
LANGUAGE SKILLS | Ability to read, analyze, and interpret health and science periodicals, professional journals, technical procedures, or governmental regulations. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the public.
MATHEMATICAL SKILLS | Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent and to draw and interpret bar graphs. Knowledgeable of advanced statistical methodology.
REASONING ABILITY | Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.
COMPUTER SKILL | To perform this job successfully, an individual should have advance knowledge and proficiency in statistical data processing and visualization software such as Tableau, Spreadsheet software, and SAS, as well as Microsoft Office, Word Processing software, and SharePoint.
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
Please apply before: 12/20/20
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.
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. Weights up to 25 pounds are occasionally lifted.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship