Medical Case Manager - Delaware; Castle

Company:
Highmark Inc.

This is a full‑time hybrid work‑from‑home and community‑based position requiring frequent travel within the assigned territory. A portion of this role involves working directly with members where they are – in‑home, hospitals, PCPs, etc. The position assures that members with complex medical and/or psychosocial needs have access to high quality, cost‑effective health care. Responsibilities include holistic assessment, planning, arranging, coordinating, monitoring, and evaluating outcomes necessary to facilitate member access to health care services.

The case manager advocates for the most appropriate care plan, uses accurate planning, and collaborates with internal and external customers and contacts. The role follows established regulatory guidelines, policies, and procedures related to member interventions and documentation. The case manager also facilitates participation in interdisciplinary and interagency meetings to coordinate services/resources.

• Communicate effectively while performing customer telephonic interviewing and communication with external contacts.
• Communicate effectively while interacting with Case Management Specialists, Management Team, Physician Advisors, and other interdepartmental contacts.
• Maintain knowledge of medical terminology and medical diagnostic categories/disease states.
• Educate members to enhance understanding of illness/disease impact and positively affect care‑plan adherence, pharmacy regimen maintenance, and health outcomes.
• Collaborate with primary care physicians, medical specialists, home health, and other ancillary health care providers to coordinate member care.
• Collect member medical information from a variety of sources, including providers and internal records, and use appropriate clinical judgement and consultation with internal physician advisors and other cross‑departmental consultation to determine unmet member needs.
• Work independently to identify, define, and resolve a myriad of problem types experienced by the member.
• Develop an individualized plan of care designed to meet each member’s specific needs.
• Anticipate member needs by continually assessing and monitoring the member’s progress toward goals, care‑plan status, and readjust goals when indicated.
• Maintain a working knowledge of available resources to address identified member needs and provide proactive and efficient services.
• Consider benefit design and cost‑benefit analysis when planning interventions to develop a realistic care plan.
• Communicate and collaborate with other payers (when applicable) to create a coordinated approach to care management and benefit coordination.
• Maintain knowledge of community resources available to assist members.
• Coordinate with community organizations/agencies to identify additional resources for which the MCO is not responsible.
• Work within a team environment: attend and participate in required meetings, including staff meetings, internal rounds, and in‑services to enhance professional knowledge and competency for overall management of members.
• Participate in departmental and/or organizational work and quality initiative teams; collaborate with peers, specialist teams, and other interdepartmental contacts.
• Participate in interagency and/or interdisciplinary team meetings to facilitate coordination of member care and resources.
• Foster effective work relationships through conflict resolution and constructive feedback skills.
• Attend internal and external continuing education forums annually to enhance clinical skills and maintain professional licensure, if applicable.
• Educate health team colleagues on the role and responsibilities of case management and the unique needs of the populations served to foster constructive and collaborative solutions.
• Other duties as assigned or requested.

• Minimum Bachelor’s degree in nursing or RN certification in lieu of a bachelor’s degree, or a Master’s degree in social work, counseling, education, or a related field, with 3 years’ experience in acute or managed care (or experience with Medicaid or Medicare populations).
• OR Bachelor’s degree in social work with five…