Job Summary:

The Community Based Care Manager collaborates with members of an inter-disciplinary care team (ICT), providers, community and faith-based organizations to improve quality and meet the needs of the individual, natural supports and the population through culturally competent delivery of care and coordination of services and supports. Facilitates communication, coordinates care and service of the member through assessments, identification and planning, and assists the member in creation and evaluation of person-centered care plans to prioritize and address what matters most, behavioral, physical and social determinants of health needs with the aim to improve the of lives our members.

Essential Functions:

• Engage the member and their natural support system through strength-based assessments and a trauma-informed care approach using motivation interviewing to complete health and psychosocial assessments through a health equity lens unique to the needs of each member that identify the cultural, linguistic, social and environmental factors/determinants that shape health and improve health disparities and access to public and community health frameworks
• Facilitate regularly scheduled inter-disciplinary care team (ICT) meetings to meet the needs of the member
• Engage with the member in a variety of settings to establish an effective, professional relationship. Settings for engagement include but are not limited to hospital, provider office, community agency, member's home, telephonic or electronic communication
• Develop a person-centered individualized care plan (ICP) in collaboration with the ICT, based on member's desires, needs and preferences
• Identify and manage barriers to achievement of care plan goals
• Identify and implement effective interventions based on clinical standards and best practices
• Assist with empowering the member to manage and improve their health, wellness, safety, adaptation, and self-care through effective care coordination and case management
• Facilitate coordination, communication and collaboration with the member the ICT in order to achieve goals and maximize positive member outcomes
• Educate the member/ natural supports about treatment options, community resources, insurance benefits, etc. so that timely and informed decisions can be made
• Employ ongoing assessment and documentation to evaluate the member's response to and progress on the ICP
• Evaluate member satisfaction through open communication and monitoring of concerns or issues
• Monitors and promotes effective utilization of healthcare resources through clinical variance and benefits management
• Verify eligibility, previous enrollment history, demographics and current health status of each member
• Completes psychosocial and behavioral assessments by gathering information from the member, family, provider and other stakeholders
• Oversee (point of contact) timely psychosocial and behavioral assessments and the care planning and execution of meeting member needs
• Participate in meetings with providers to inform them of Care Management services and benefits available to members
• Assists with ICDS model of care orientation and training of both facility and community providers
• Identify and address gaps in care and access
• Collaborate with facility based case managers and providers to plan for post-discharge care needs or facilitate transition to an appropriate level of care in a timely and cost-effective manner
• Coordinate with community-based case managers and other service providers to ensure coordination and avoid duplication of services
• Appropriately terminate care coordination services based upon established case closure guidelines for members not enrolled in contractually required on going care coordination.
• Provide clinical oversight and direction to unlicensed team members as appropriate
• Document care coordination activities and member response in a timely manner according to standards of practice and CareSource policies regarding professional documentation
• Continuously assess for areas to improve the process to make the members experience with CareSource easier and shares with leadership to make it a standard, repeatable process
• Regular travel to conduct member, provider and community-based visits as needed to ensure effective administration of the program
• Adherence to NCQA standards (CMSA standards below)
• Perform any other job duties as requested

Education and Experience:

• Nursing degree from an accredited nursing program or Bachelor's degree in a health care field or equivalent years of relevant work experience is required
• Licensure as a Registered Nurse, Professional Clinical Counselor or Social Worker is required
• Advanced degree associated with clinical licensure is preferred
• A minimum of three (3) years of experience in nursing or social work or counseling or health care profession (i.e. discharge planning, case management, care coordination, and/or home/community health management experience) is required
• Three (3) years Medicaid and/or Medicare managed care experience is preferred

Competencies, Knowledge and Skills:

• Strong understanding of Quality, HEDIS, disease management, supportive medication reconciliation and adherence
• Intermediate proficiency level with Microsoft Office, including Outlook, Word and Excel
• Ability to communicate effectively with a diverse group of individuals
• Ability to multi-task and work independently within a team environment
• Knowledge of local, state & federal healthcare laws and regulations & all company policies regarding case management practices
• Adhere to code of ethics that aligns with professional practice
• Knowledge of and adherence to Case Management Society of America (CMSA) standards for case management practice
• Strong advocate for members at all levels of care
• Strong understanding and sensitivity of all cultures and demographic diversity
• Ability to interpret and implement current research findings
• Awareness of community & state support resources
• Critical listening and thinking skills
• Decision making and problem-solving skills
• Strong organizational and time management skills

Licensure and Certification:

• Current unrestricted clinical license in state of practice as a Registered Nurse, Social Worker or Clinical Counselor is required. Licensure may be required in multiple states as applicable based on State requirement of the work assigned
• Case Management Certification is highly preferred
• Must have valid driver's license, vehicle and verifiable insurance. Employment in this position is conditional pending successful clearance of a driver's license record check and verified insurance. If the driver's license record results are unacceptable, the offer will be withdrawn or, if employee has started employment in position, employment in the position will be terminated.
• Employment in this position is conditional pending successful clearance of a criminal background check. Results of the criminal background check may necessitate an offer of employment being withdrawn or, if employee has started in position, termination of employment.
• To help protect our employees, members, and the communities we serve from acquiring communicable diseases, Influenza vaccination is a requirement of this position. CareSource requires annual proof of Influenza vaccination for designated positions during Influenza season (October 1 - March 31) as a condition of continued employment. Employees hired during Influenza season will have thirty (30) days from their hire date to complete the required vaccination and have record of immunization verified.
• CareSource adheres to all federal, state, and local regulations. CareSource provides reasonable accommodations to qualified individuals with disabilities or medical conditions, sincerely held religious beliefs, or as required by state law to enable the employee to perform the essential functions of the position. Request for accommodations will be completed through an interactive review process.

Working Conditions:

• This is a mobile position, meaning that regular travel to different work locations, including homes, offices or other public settings, is essential. Will be exposed to weather conditions typical of the location and may be required to stand and/or sit for long periods of time.
• Must reside in the same territory they are assigned to work in; exceptions may be considered, due to business need
• May be required to travel greater than 50% of time to perform work duties.
• Required to use general office equipment, such as a telephone, photocopier, fax machine, and personal computer
• Flexible hours, including possible evenings and/or weekends as needed to serve the needs of our members

HCQI Model Role: CM

Does this job title support quality? Yes

Detailed description of HCQI activities performed:

Provides care coordination to member through:

• Closing gaps in care and barriers to care including addressing access to care and SDOH needs
• Member education
• Empowering member to self-manage
• Establishing Care Plan Goals
• Disease and condition management
• Promote medication adherence
• Coordinate transitions of care

Percentage of time spent on HCQI activities:

• Case Management: 50%
• Disease Management: 10%
• Discharge Planning/Readmission Prevention: 10%
• Medical Director Oversight: 0%
• Medication Therapy Management: 10%
• Community Advocacy: 5%
• Quality Data Analytics & Reporting: 5%
• Provider Engagement: 5%
• Technology that Supports Quality Initiatives: 0%
• Other: 0%
• Total Time Spent on HCQI Activities: 95%

HCQI Activities Category: Improve Health Outcomes

Compensation Range:
$60,300.00 - $96,500.00 CareSource takes into consideration a combination of a candidate's education, training, and experience as well as the position's scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. We are highly invested in every employee's total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type:
Salary

Competencies: