Care Manager, Pediatric - Multiple Openings/ REMOTE

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 environment in 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.