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.
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:
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Education Level: Registered Nurse
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
CCM/ACM or other RN Board Certified certification in case management. Federal Employee Program (FEP) Book of Business (ONLY): Must have CCM/ACM or other RN Board Certified certification in case management. Incumbents not certified at the time of hire must have two years of case management experience and meet requirements to take CCM or ACM exam and successfully achieve the certification within the first year of employment.
Licenses/Certifications:
RN – Registered Nurse – State Licensure And/or Compact State Licensure RN- Registered Nurse in MD, VA or Washington, DC
Accredited Case Manager (ACM) Federal Employee Program (FEP) Book of Business (ONLY): Must have CCM/ACM or other RN Board Certified certification in case management. Incumbents not certified at the time of hire must have two years of case management experience and meet requirements to take CCM or ACM exam and successfully achieve the certification within the first year of employment OR
CCM – Certified Case Manager Federal Employee Program (FEP) Book of Business (ONLY): Must have CCM/ACM or other RN Board Certified certification in case management. Incumbents not certified at the time of hire must have two years of case management experience and meet requirements to take CCM or ACM exam and successfully achieve the certification within the first year of employment. Upon Hire Pref
Knowledge, Skills and Abilities (KSAs)
Knowledge of clinical standards of care and disease processes.
Ability to produce accurate and comprehensive work products with minimal direction
Ability to triage immediate member health and safety risks.
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)
Excellent verbal and written communication skills, along with the telephonic and keyboarding skills necessary to assess, coordinate and document services for members.
Knowledgeable of available community resources and programs.
Proficient in the use of web-based technology and Microsoft Office applications such as Word, Excel and PowerPoint
Ability to provide excellent internal and external customer service
Department
Department: DC Medicaid- Clinical Enterprises
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
Closing Date
Please apply before: 11/3/21
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. Weights up to 25 pounds are occasionally lifted.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship