Care Manager I, Specialty Programs (Hunterdon & Somerset Counties)

About the role

The Care Manager I – Specialty Programs is responsible for performing care coordination duties using established guidelines to ensure appropriate level of care as well as planning for the transition to the continuum of care for specialty populations. This position implements interventions to ensure efficient utilization of benefits.

Responsibilities

• Assess member’s clinical need against establish guidelines and/or standards for specialty population-based members.
• Implement the delivery of high quality, cost-effective care based on a customized population model of care supported by clinical practice guidelines established by the plan.
• Partner with the member/family, physician, and all members of the healthcare team to ensure the member’s needs are met, internal and external to this organization.
• Advocate for the member among various sites to coordinate resource utilization.
• Utilize the care management process to set priorities, plan, organize, and implement interventions that are goal directed toward self-care outcomes, and the transition to independent status.
• Ensure care for mandated non-compliant members through the monitoring of utilization.
• Document accurately and comprehensively based on the standards of practice and current organization policies.
• Evaluate care by problem solving, analyzing variances, and participating in quality improvement to enhance member outcomes.
• Monitor member’s care activities, regardless of the site of service or network participation, and outcomes for appropriateness and effectiveness.
• Consult with internal stakeholders on complex cases and escalate as appropriate to internal physician resources.
• Complete other assigned functions as requested by management.

Education/Experience

Requires a license as an RN, or Bachelor degree in social work, health or behavioral science. Graduate level degree in Social Work or Health and Behavioral Science preferred. Requires a minimum of three (3) years’ experience serving members with special needs.

Knowledge

• Requires strong knowledge of the standards of practice for case managers.
• Requires strong knowledge of managed care principles.
• Requires strong knowledge of specialty population, as applicable.

Skills

• Requires strong organizational skills.
• Requires strong oral and written