Senior Complex Case Manager

Primary Responsibilities :

• Conducts clinical evaluation of members per regulated timelines, determining who may qualify for complex case management based on clinical judgment, changes in member's health, social determinants, and gaps in care
• Creates and implements a case management plan in collaboration with the member, caregiver(s), provider(s), and / or other appropriate healthcare professionals to address the patient's needs and goals
• Performs ongoing updates of the care plan to evaluate effectiveness, and to document barriers, interventions, and goal achievement
• Partners with primary providers or multidisciplinary team members to align or integrate goals to plan of care
• Completes home, facility, clinic and telephonic visits for member engagement and enrollment
• Uses motivational interviewing to evaluate, educate, support, and motivate change during member contacts
• Identifies and considers appropriate options to mitigate issues related to quality, safety or affordability when they are identified, and escalates to ensure optimal outcomes, as needed
• Ensures compliance with quality metrics specific to health plan delegation and accrediting body requirements
• Conducts self and peer audits on a regular and assigned timeline
• Maintains caseload per defined medical management department standards
• Sustains productivity and audit requirements per medical management department standards
• Demonstrates ability to work independently and implement innovative approaches to complex member situations
• Sought out as expert and serves as leader / mentor / preceptor to other members of medical management team.
• Determines need for continued member management, creates care plan and facilitates transition to medical management programs
• Serves as facilitator and resource for other members of the Medical Group clinical team
• Attends departmental meetings and provides constructive recommendations for process improvement
• Performs other duties as assigned

You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications :