Medical Case Manager

Company :

Job Description : 

JOB SUMMARY

The Triage Clinical Nurse Care Coordinator plays a pivotal role in ensuring members with complex medical, behavioral health, and social determinants of health (SDOH) needs receive timely access to high-quality, cost-effective care. This position is responsible for triaging member assignments based on a comprehensive assessment of their clinical and social needs, matching them with the most appropriate care team member. Using sound clinical judgment, the Coordinator facilitates the holistic assessment of member needs, care planning, and coordination of services. The Coordinator will advocate for optimal care plans and staff assignments through collaboration with internal and external stakeholders. This role adheres to all regulatory guidelines, policies, and procedures related to member assignment, interventions, and accurate documentation of care progression. The Coordinator actively participates in interdisciplinary meetings to ensure seamless coordination of services and resources for our members.

ESSENTIAL RESPONSIBILITIES

• Communicate effectively while performing customer telephonic interviewing and communication with external contacts.

• Communicate effectively while interacting with Case Management Specialists, Management Team, Physician Advisors and other interdepartmental contacts.

• Maintain knowledge of Medical Terminology and Medical Diagnostic Categories/Disease States

• Educate members to enhance member understanding of illness/disease impact and to positively impact member care plan adherence, pharmacy regimen maintenance, and health outcomes.

• Collaborate with Primary Care Physicians, Medical Specialists, Home Health and other ancillary healthcare providers with the goal being to coordinate member care.

• Collect member medical information from a variety of sources including providers and internal records and use appropriate clinical judgment, consultation with internal Physician Advisors and other internal cross-departmental consultation to determine unmet member needs.

• Work primarily independently to identify, define, and resolve a myriad of problem types experienced by the member.

• Develop an individualized plan of care designed to meet the specific needs of each member.

• Anticipate the needs of members by continually assessing and monitoring the member’s progress toward goals, care plan status, and re-adjust goals when indicated.

• Maintain a working knowledge of available resources for addressing identified member needs and to facilitate proactive and efficient provision of services. 

• Be knowledgeable of and consider benefit design and cost benefit analysis when planning a course of intervention to develop a realistic plan of care.

• Communicate and collaborate with other payers (when applicable) to create a collaborative approach to care management and benefit coordination.

• Maintain a working knowledge of available community resources available to assist members.

• Coordinate with community organizations/agencies for the purpose of identifying additional resources for which the MCO is not responsible.

• Work within a Team Environment.

• Attend and participate in required meetings, including staff meetings, internal Rounds, and other in-services to enhance professional knowledge and competency for overall management of members.

• Participate in departmental and/or organizational work and quality initiative teams.

•  Case collaborate with peers, Case Management Specialists, Management Team, Physician Advisors and other interdepartmental contacts.

• Participate in interagency and/or interdisciplinary team meetings when necessary to facilitate coordination of member care and resources.

• Foster effective work relationships through conflict resolution and constructive feedback skills.

• Attend internal and external continuing education forums annually to enhance overall clinical skills and maintain professional licensure, if applicable.

• Educate health team colleagues of the role and responsibility of Case Management and the unique needs of the populations served to foster constructive and collaborative solutions to meet member needs.

• Other duties as assigned or requested.

QUALIFICATIONS

Minimum

• Bachelor’s degree in nursing or RN certification in lieu of bachelor's degree or Master’s degree in Social Work, Counseling, Education, or related field and 3 years' experience in Acute or Managed Care/ experience with Medicaid or Medicare populations.  OR

• Bachelor’s degree in Social Work with five years’ experience in Acute or Managed Care/ experience with Medicaid or Medicare populations

Preferred

• Demonstrated experience and expertise in multiple areas of healthcare, including but not limited to: pediatrics, maternity, behavioral health, chronic conditions, substance use, and transition of care.
• 3 years of experience in working in Acute Care/Managed Care/Medicaid and Medicare populations.
• Case Management Certification
• Proficiency in Electronic Health Records (EHR): Experience with navigating and documenting within EHR systems is crucial for efficient record-keeping and communication.
• Proficient in Microsoft Office Suite, with advanced Excel skills.
• Critical Thinking and Problem-Solving: The ability to assess complex situations, identify problems, and develop effective solutions is essential.

LICENSES AND CERTIFICATIONS

Required

• Licensed Social Worker (LSW)-Non-Specific - State (OR) Registered Nurse - Non-Specific (OR) Licensed Professional Counselor (LPC) – Non-Specific State (OR) Licensed Bachelors Social Worker (LBSW)

Preferred

• None

Skills

• None

SCOPE OF RESPONSIBILITY

Does this role supervise/manage other employees?

No    

WORK ENVIRONMENT

Is Travel Required?

No

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times.  In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. 

Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

Pay Range Minimum:

Pay Range Maximum:

Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations.  The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.

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