Care Manager, Medicare Stars

Job Summary

Hybrid Work Environment - Must reside in Hawaii
Pay Range: $68,000 - $133,000
Note: Individuals typically begin between the minimum to middle of the pay range

About the Role

The Care Manager, Medicare Stars is an experienced licensed healthcare professional responsible for closing Medicare Stars care gaps. The care manager is accountable for achieving organizational goals and key performance indicators (KPIs), with a focus on enhancing member experience, reducing morbidity, mortality, and hospital utilization, and minimizing overall healthcare costs.

Responsibilities

• Conduct comprehensive assessments, including physical, psychosocial, and health literacy evaluations, and interpret relevant diagnostic data to identify member and family needs.
• Analyze complex cases using critical thinking skills to determine underlying causes contributing to high costs and develop individualized transition/treatment plans to address care gaps.
• Empower members to develop actionable care plans that help prevent avoidable utilization and communicate results to internal and external departments and business partners.
• Assess educational needs of members and families and ensure they receive clear and sufficient information to facilitate active participation in care gap closure.
• Inspire quality improvement initiatives, support leadership in system-level improvements, analyze dashboard data for program enhancement, and mentor new staff to promote best practices.
• Perform all other miscellaneous responsibilities and duties as assigned or directed.

Requirements

• At least three years of relevant clinical experience in medical-surgical, community or home health care, or equivalent experience in reviewing members' medical care and services.
• Must meet facility specified health screening/annual competency requirements.
• Demonstrates thorough expertise in care transitions with little supervision required.
• Possesses strong documentation and research abilities, can analyze information, make decisions, and communicate effectively both verbally and in writing.
• Displays interpersonal skills, resolves conflicts, and acts with integrity.
• Highly organized, able to multitask independently, fosters adaptability and teamwork.
• Performs well in a fast-paced setting and readily adapts to changes.
• Delivers outstanding customer service to both internal and external clients.
• Utilizes excellent analytical and critical thinking to evaluate medical necessity and the suitability of patient services and treatment individually.
• Safeguards patient privacy in accordance with Federal (HIPAA), organizational, and departmental regulations.
• Clearly communicates with providers and health care teams while building collaborative relationships.
• Intermediate working knowledge in Microsoft Office applications, including but not limited to Word, Excel, Outlook, and PowerPoint.
• Experience with electronic medical records.
• Valid current Hawaii Registered (RN) or Registered Pharmacist (RPh).

Qualifications

• Valid current Hawaii Registered (RN) or Registered Pharmacist (RPh).