Description and Requirements

The Care Manager plans and manages behavioral and/or physical care with members and their beneficiaries and works with clinicians and health care team members. The Care Manager facilitates care and medical attention and addresses identified member needs across the continuum of care. The Care Manager is responsible for applying care management principles when engaging members and addressing coordination of the member's health care services. The Care Manager is assigned to a specific product line such as CompleteCare, SNP, Medicaid/Medicare, PHSP, HARP, etc.

The 'Complex Care' Care Manager takes a holistic (medical, behavioral, psychosocial) approach to planning and managing the care of members with chronic diseases like asthma, congestive heart failure and COPD. The Care Manager works with members, care givers and/or providers to ensure appropriate access to care, adherence to treatment plans and improvement in outcomes.

• Advocates, informs, and educates beneficiaries on services, self-management techniques, and health benefits.
• Conducts assessments to identify barriers and opportunities for intervention.
• Develops care plans that align with the physician's treatment plans and recommends interventions that align with proposed goals.
• Generates referrals to providers, community-based resources, and appropriate services and other resources to assist in goal achievement.
• Collaborates with provider doctors, social workers, discharge planners, and community based service providers to coordinate care accordingly.
• Coordinates and facilitates with the multi-disciplinary health care team as necessary in order to ensure care plan goals are achieved and maximize member outcomes.
• Assists in identifying opportunities for alternative care options based on member needs and assessments.
• Evaluates service authorizations to ensure alignment and execution of the member's care and physician treatment plan.
• Contributes to corporate goals through ongoing execution of member care plans and member goal achievement.
• Documents all encounters with providers, members, and vendors in the appropriate system in accordance with internal and established documentation procedures; follows up as needed; and updates care plans based on member needs, as appropriate.
• Occasional overtime as necessary.
• Additional duties as assigned.

• NYS RN or
• LCSW, LMSW

• Strong interpersonal and assessment skills, especially the ability to relate well with seniors, their families, and community care providers, along with demonstrated ability to handle rapidly changing crisis situations.
• Fluency in Spanish, Korean, Mandarin, or Cantonese.
• Knowledge and experience with the current community health practices for the frail adult population and cognitive impaired seniors.
• Knowledge of InterQual and LOCADTR.
• Experience managing member information in a shared network environment using paperless database modules and archival systems.
• Experience and knowledge of the relevant product line
• Relevant work experience preferably as a Care Manager
• Demonstrated ability to manage large caseloads and effectively work in a fast-paced environment
• Proficient with simultaneously navigating the Internet and multi-tasking with multiple electronic documentation systems
• Experience using Microsoft Excel with the ability to edit, search, sort/filter and other Microsoft and PHI systems
• Experience with Care Management and/or chronic disease management