Medical Care Manager

The Medical Care Manager works collaboratively with the health care team to manage and coordinate care for a specific population of members whose needs represent high clinical and social risk in order to ensure quality and cost-effective member-centered care.

Responsibilities include, but are not limited to the following:

• Practice case management within the scope of licensure.
• Utilizes case management principles and sound clinical judgment in coordinating care for a specific member population
• Performs intensive case management functions for identified individuals in order to promote quality, cost-effective outcomes, including but not limited to:

• Performing a Comprehensive Functional Needs assessment
• Performing a Transitions of Care assessment
• Care planning activities including the development of interventions, short and long-term goals in collaboration with member, family, PCP, Behavioral Health Professionals and other involved health care professionals and community agencies, as appropriate
• Communicate with providers to facilitate needed care
• Implements care plan, facilitates referrals, coordinates services and resources and provides ongoing monitoring and re-evaluation of outcomes
• Continuous monitoring and evaluation of the care outcomes and identification of service gaps
• Regular review and revision of the plan of care in collaboration with the family and appropriate members of the health care team based on the outcomes and evaluative findings
• Off-site visits (such as but not limited to home, hospital or community health centers or other community agencies) as necessary or required
  • Provides comprehensive documentation of all activities and contacts in Case Management software system
  • Facilitates referrals and coordinates needed services
  • Collaborates with team as necessary in identifying needed services and supports
  • Communicates with ancillary departments, such as Provider Relations and Member Services, as necessary to meet individual needs of members and providers
  • Meets department and regulatory standards for accuracy, proficiency and documentation in order to communicate decisions and plan of care in an appropriate and timely manner
  • Provides clinical oversight to community outreach and other team members; providing direct supervision of community outreach staff as appropriate regarding individual case status
  • Serves as a clinical resource to respond to questions from various departments
  • Provides cross-coverage as assigned
  • Participates in outreach/marketing activities as needed and as appropriate
  • Other duties as assigned
  • Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhoods Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies and procedures as it applies to individual job duties, the department, and the Company. This position must exercise due diligence to prevent, detect and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents

Qualifications

Required

• Registered Nurse with an active, current, unrestricted license in RI in good standing (Consideration will be given to individuals without current RI license. Must provide documentation confirming RI RN application within 24 hours of offer) OR
• Masters degree with active, current, unrestricted LICSW or LCSW license in RI in good standing
• Minimum of three (3) years care management or community health nursing experience
• Demonstrated experience in Medicare/Medicaid (MMP), Medicaid, Medicare or commercial products
• PC based software programs intermediate level of proficiency
• Strong organizational and interpersonal skills
• Customer service orientation
• Ability to work independently and prioritize activities
• Must have access to reliable transportation. If using personal vehicle, must have active drivers license and auto insurance

Preferred:

• Managed Care experience
• Two to Four (2-4) years experience in acute care
• BSN or Certification as a CM
• Clinical specialty experience
• Bilingual

Core Company-Wide Competencies:

• Communicate Effectively
• Respect Others & Value Diversity
• Analyze Issues & Solve Problems
• Drive for Customer Success
• Manage Performance, Productivity & Results
• Develop Flexibility & Achieve Change

Job Specific Competencies:

• Collaborate & Foster Teamwork
• Create & Innovate
• Plan & Organize
• Exercise Sound Judgement & Decision Making

Travel Expectations:

• Travel 25-50% of the day. Must have access to reliable transportation.

Neighborhood Health Plan of Rhode Island is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.