SCOPE OF ROLE

The role of the Case Manager is to promote quality, cost-effective outcomes for a population by facilitating collaboration and coordination across settings, assessing member needs, planning for care, monitoring the efficacy of interventions, and advocating to ensure member’s receive services and resources required to meet desired health and social outcomes. The Case Manager is responsible for providing patient centered care across the care continuum.

ROLE RESPONSIBILITIES

• Assessment of the medical, social, and behavioral needs of an assigned population
• Care Plan development and prioritization to transition members to optimal levels of health and self-management.
• Capacity to coordinate interdisciplinary team meetings as required
• Collaboration across providers and healthcare settings to ensure optimal quality outcomes for an assigned population
• Provide transition of care interventions as required
• Facilitate care coordination, self-management planning, discharge planning, and health education for an assigned population.
• Facilitate linkage to appropriate community resources to address social determinants of health
• Capacity to adjudicate referrals and apply evidence-based clinical criteria to coordinate member care needs across all care setting
• Able to ensure member communication and notices are composed in a manner consistent with regulatory standards.
• Adheres to the Policies and Procedures set forth by the Quality Management Committee

EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE

• Associate’s degree in Nursing, Bachelor’s degree preferred
• Minimum two (2) years of experience in medical management clinical functions
• Working knowledge of MCG, InterQual, and NCQA standards

LICENSURES AND CERTIFICATIONS

• Active and unrestricted license as a Registered Nurse (RN) in the state of CA is required
• Certification in Case Management (CCM) or Managed Care Nursing (CMCN) preferred

WORK ENVIRONMENT

• The majority of work responsibilities are performed in an open office setting, carrying out detailed work sitting at a desk/table and working on the computer.
• Some travel may be required.

We’re Making Healthcare Right. Together.

We are realizing a completely different healthcare experience where payors, providers, doctors, and patients can all feel connected, aligned and unified on the same team. By eradicating the frictions of competing needs, we are making it possible to give everyone more of what they want and deserve. We do this by:

Focusing on Consumers
We understand patient pain points, eliminating complexity while increasing transparency, for greater access and easier navigation.

Building on Alignment
We integrate and align individual incentives at all levels, from financing to optimization to delivery of care.

Powered by Technology

We employ our purpose built, integrated data platform to connect clinical, financial, and social data, to deliver exceptional outcomes.

As an Equal Opportunity Employer, we welcome and employ a diverse employee group committed to meeting the needs of Bright Health, our consumers, and the communities we serve. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.