The role of the Case Manager is to promote quality, cost-effective outcomes for a population by facilitating collaboration and coordination across settings, identifying 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

• Collect relevant clinical data to support the care planning process
• Care Plan support, intervention, and prioritization to transition members to optimal levels of health and self-management
• Participate in 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
• Adjudicate referrals and apply evidence-based clinical criteria to coordinate member care needs across all care setting
• 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 and performs all additional duties as assigned

EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE

• Associate’s degree in Nursing, preferred
• Minimum 2 years of experience in medical management clinical functions.
• Working knowledge of MCG, InterQual, and NCQA standards
• Bilingual in English and Spanish
  

LICENSURES AND CERTIFICATIONS

• Active and Unrestricted License as a Licensed Vocational Nurse (LVN)
• Certification Managed Care Nursing (CMCN) preferred

PROFESSIONAL COMPETENCIES

• High level of critical thinking and problem-solving skills
• Strong work ethic and overall positive attitude
• Effective communication skills including verbal and written
• Ability to manage time effectively, understand directions, and work independently in a fast-paced environment
• Demonstrated flexibility, organization, and self-motivation
• Highly adaptable to change