Clinical Care Manager

Job Summary

The Clinical Care Manager provides holistic medical care management services for members throughout the continuum of care by assessing the member clinically as well as member's readiness to make behavioral changes and actively participate in a care plan, establish goals and meet those goals. Members may include those who have chronic conditions and complex care needs, including those considered to be the highest risk members those who are homeless, undergoing organ transplantation, have multiple clinical and behavioral co-morbid conditions, and with special health care needs.

The clinician works collaboratively with a multidisciplinary team (both internal and external) including providers, our clinical vendor partners (behavioral health, pharmacy, etc.) and community/ State agencies to increase patient knowledge, motivation, and compliance with treatment through targeted interventions that address the member's holistic needs from a medical and psychosocial/socioeconomic standpoint. Following this approach, the goal is to improve member health outcomes and decrease overall cost while improving the member's overall experience with the health care delivery system.

Utilizing both telephonic outreach and face to face member visits and through the use of assessments, real-time data, motivational interviewing techniques and evidence-based practices, the Clinical Care Manager engages with the member and the multidisciplinary team to develop an Individual Care Plan (ICP) that emphasizes self-management goals, care coordination, psychosocial, socioeconomic, and community-based supports and on-going monitoring and appropriate follow up.

The Clinical Care Manager identifies and addresses barriers to optimal self-management and works with the member, their support persons, and team to coordinate care throughout the health care continuum, assisting the member to access all available benefits and resources including family support and community resources, with a goal of promoting appropriate utilization of services at the appropriate level and site of care such as preventing ambulatory sensitive emergency department visits and inpatient admissions, avoiding readmissions, and encouraging the member to keep scheduled outpatient appointments to include preventive care visits.

The clinical care manager may meet members in their homes, shelters, provider offices, medical facilities, and at locations agreed upon with the member.

• Full-time remote work
• Competitive salaries
• Excellent benefits

• Completes a targeted general assessment and applicable condition specific assessments.
• Evaluates members' need for complex care management, disease management or chronic condition management.
• Collaboratively develops an individual care plan with the member focusing on the member's goals and objectives, identifying strategies, supports and/or services needed to achieve short and long term goals.
• Identifies and addresses barriers to optimal self-management and works with the member and team to coordinate care throughout the health care continuum.
• Assists the member to access all available benefits and resources including family support and community resources.
• Utilizes motivational interviewing techniques to engage members in care management and to coach members regarding health promotion, disease management and preventive health strategies.
• Uses real-time data from electronic medical records, where available.
• Uses reporting to access member medical and pharmacy utilization reports, sharing with PCP, to promote medication compliance and action plans.
• Supports and enhances the member's capacity to self-manage.
• Evaluates the effectiveness of the care management provided to the member on an on-going basis and updates the ICP accordingly.
• Utilizes evidence-based practices and guidelines to educate members on specific disease processes.
• Provides or arranges for resources necessary to meet members' social determinants of health care needs including but not limited to psychosocial and socioeconomic needs.
• Promotes and encourages member collaboration with the primary care provider and other health care providers.
• Completes documentation in the medical management information system real-time during face-to-face meetings, by phone, and in a timely manner and in keeping with contractual requirements, internal policy and NCQA accreditation standards. Facilitates multidisciplinary consultation on members' behalf through participation in rounds, team meetings and clinical reviews.
• Conducts face-to-face visits with members and providers, community and state agencies, as appropriate.
• Regular and reliable transportation and the ability to conduct face-to-face appointments with members, providers, community and state agencies
• Assists with staff training and mentoring.
• Refers cases to Social Care Management, Behavioral Health Care Management, and Community Health Worker staff, as clinically indicated.
• Consults with and…