High Risk Maternity Transition of Care Management - Remote
15 hours ago
New York
Summary of Position • Provide care management, as part of a multi-disciplinary care team, that includes care coordination, performing telephonic or face-to-face assessments of members' health care needs, identifying gaps in care and needed support, administering/coordinating implementation of interventions., • Support and enable members to manage their physical, environmental and psycho-social concerns, understand and appropriately utilize their health plan benefits and remain safe and independent in their home or current living environmentin collaboration with health care providers., • Provide Care Management services to identified high risk members within the community, including but not limited to Physician Practices, Retail Centers/Neighborhood Care Centers, and members' homes., • Coordinate and provide care that is safe, timely, effective, efficient and member-centered to support population health, transitions of care, and complex care management initiatives., • Engage with the most complex members of the health plan with the goal of improving health care outcomes and appropriate and timely utilization of services across the continuum of care., • Assist the entire Care Management interdisciplinary team in managing members with Care Management needs. Principal Accountabilities • Assess and evaluate the needs of our most complex members, acting as the clinical coordinator collaborating with members, caregivers, providers, multi-disciplinary team, and health care and community resources through a variety of assessments to identify areas of (medical, financial, environmental, health insurance benefit, psycho-social, caregiving) concerns and potential gaps in care utilizing the most appropriate resources to support members' needs., • Identify appropriate goals, strategies and interventions that may include referrals, health education, activation of community-based resources, life planning, or program/agency referrals based on areas of concern., • Develop, communicate and evaluate medical management strategies and interventions including potential for alternative solutions to ensure high quality, cost effective continuum of care with the member, caregiver, provider(s) and multidisciplinary team., • Include member and family as appropriate., • Engage actively with the member PCP / designee., • Engage with the member in support of their treatment team to identify and establish attainable goals that positively impact clinical, financial, and quality of life outcomes for member., • Work collaboratively with all stake holders to ensure knowledge of the action plan, including participation in telephonic and face-to-face case conferences when appropriate., • Assess the needs of members and align them with the appropriate member of the care team (wellness team, registered dietitian, social worker, community health workers)., • Act as the member's advocate and liaison by completing or facilitating interventions with providers and/or private,non-profit, and governmental agencies., • Ensure that all Care Management processes and reporting are compliant with all applicable federal and state regulations, and NCQA and company standards., • Participate in delegation collaboration activities, as required., • Research evidence-based guidelines, medical protocols, provider networks, and on-line resources in making care management recommendations., • Enter and maintain documentation in the Electronic Medical Records System (EMR), meeting defined timeframes and performance standards., • Maintain an understanding of Care Management principles, program objectives and design, implementation, management, monitoring, and reporting., • Actively participate on assigned committees., • Attend and complete all department-mandated training as well as satisfy educational in-service requirements., • Perform other related projects and duties as assigned., • Provide ongoing monitoring, evaluation, support and guidance to the coordination of the member's health care., • Develop, implement and coordinate plan of care and facilitate members' goals., • Coordinate interdisciplinary team tasks and activities, with the goal of maintaining team performance and high morale. Qualifications Education, Training, Licenses, Certifications • Bachelor's degree., • RN required, with current active RN license., • CCM certification preferred., • Certification in utilization or care management preferred. Relevant Work Experience, Knowledge, Skills, and Abilities • 4 - 6 years of clinical experience., • Organization/prioritization ability; and the ability to effectively manage a caseload of highly complex members., • Support an integrated care model tapping into appropriate resources both internally and external to the organization., • Experience in case management/care coordination, managed care, and/or utilization management., • Strong communication skills (verbal, written, presentation, interpersonal)., • Trained in the use of Motivational Interviewing techniques., • Experience working in medical facility or practice and/or with electronic medical records., • Computer proficiency: MS Office (Word, Excel, PowerPoint, Outlook); mobile technology (wireless phone/laptop, etc.), • System user experience in a highly automated environment., • Bilingual ability (verbal, written)., • Strong cross-group collaboration, teamwork, problem solving, and decision-making skills., • Ability to work a flexible schedule (evenings, weekends and holidays) to meet member and/or caregiver and departmental scheduling needs. Additional Information, • Requisition ID: 1000002945, • Hiring Range: $68,040-$118,800