Resp & Qualifications
Under minimal supervision, the Care Manager researches and analyzes a member’s medical and behavioral health needs and healthcare cost drivers. The Care Manager works closely with members and the interdisciplinary care team to ensure members have an effective plan of care and positive member experience that leads to optimal health and cost-effective outcomes. The Care Manager – Quality focuses on ensuring Medicaid and Medicare members medication adherence on NCQA Stars and HEDIS measures. Uses expertise in HEDIS and other technical quality measures and advanced member engagement techniques to ensure improved population health and accreditation results.
Identifies members with acute/complex medical and/or behavioral health conditions. Engages onsite and/or telephonically with member, family and providers to develop a comprehensive plan of care to address the member’s needs at various stages along the care continuum. Identifies relevant CareFirst and community resources and facilitates program, network, and community referrals.
Collaborates with member and the interdisciplinary care team to develop a comprehensive plan of care to identify key strategic interventions to address member’s medical, behavioral and/or social determinant of health needs. Engage members and providers to review and clarify treatment plans ensuring alignment with medical benefits and policies to facilitate care between settings. Monitors, evaluates, and updates plan of care over time focused on member’s stabilization and ability to self manage. Ensures member data is documented according to CareFirst application protocol and regulatory standards.
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Experience: 5 years clinically related experience working in Care Management, Discharge Coordination, Home Health, Utilization Review, Disease Management or other direct patient care experience.
Licenses/Certifications: RN – Registered Nurse – State Licensure And/or Compact State Licensure RN- Registered Nurse in MD, VA or Washington, DC Upon Hire Req
- Bachelors degree in nursing.
- Medicaid and/or Medicare experience.
- Knowledge and experience with CQA .
- Previous experience in member and provider engagement to influence behavior change and improved health outcomes.
Knowledge, Skills and Abilities (KSAs)
Knowledge of clinical standards of care and disease processes.
Ability to produce accurate and comprehensive work products with minimal direction.
Ability to triage immediate member health and safety risks.
Basic understanding of the strategic and financial goals of a health care system or payor organization, as well as health plan or health insurance operations (e.g. networks, eligibility, benefits).
Excellent verbal and written communication skills, along with the telephonic and keyboarding skills necessary to assess, coordinate and document services for members.
Knowledgeable of available community resources and programs
Proficient in the use of web-based technology and Microsoft Office applications such as Word, Excel and PowerPoint
Ability to provide excellent internal and external customer service
Department: MD Medicaid -QUALITY
Equal Employment Opportunity
CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.
Hire Range Disclaimer
Actual salary will be based on relevant job experience and work history.
Where To Apply
Please visit our website to apply: www.carefirst.com/careers
Please apply before: 10/07/21
Federal Disc/Physical Demand
Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.
The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship