Center Complex Care Manager

Duties And Responsibilities

• Attend member visits at their primary care provider or specialist office appointment and provide follow-up support for care coordination needs.
• Complete comprehensive assessment and person-centered care plans (PCCP) for each member on the assigned caseload.
• Manage person-centered care plans and member contact in compliance with all agency requirements, internal protocols, and accreditation standards.
• Develop, implement, and maintain person-centered care plans using SMART goals.
• Maintain up to date PCCPs in the electronic health record, including objective measures to track progress required to successfully track and complete treatment plan goals.
• Provide education with teach back regarding medical, behavioral, and functional health conditions, symptoms, and treatment options.
• Provide evidence-based clinical interventions centered on established person-centered care plan goals using a variety of approaches, e.g., trauma informed care, harm reduction, behavior change modalities, motivational interviewing, teach back methods and problem solving.
• Meet established Key Performance Indicators.
• Manage assigned caseload based on contact frequency requirements and utilization data.
• Provide crisis interventions, as appropriate.
• Proactively mitigate/resolve barriers to care to increase adherence to treatment plan.
• Collaborate with the ICT to update the team on member progress and needs and provide CCM recommendations for members to stabilize health and overcome barriers to social determinants of health.
• Aid members in accessing and engaging with services and resources.
• Maintain schedule in the clinical system and document all interactions within 1 business day.
• Actively participate in required meetings.
• Follow up on member compliance to service or resource referrals.

Minimum Qualifications

• Licensed clinician (RN, LCSW, LMSW, LMHC, LPC) by the state in which practicing and abide by all laws, regulations, and requirements.
• Preference given to qualified case managers with CCM credentials. CMGT-BC, CCTM, C-SWCM, C-ASWCM, ACM or FAACM will be considered.
• Preference given to RN candidates with experience in medical and behavioral healthcare or PMH-BC credentialed –or– SW/Counselor candidates with experience in medical settings or medical case manager roles (Infectious Disease, HIV, Hepatitis C, Organ Transplants).
• In lieu of CCM credential, 3+ integrated case management experience. Must obtain CCM within 24 months of hire date.
• 3+ years of experience in serving the needs of complex populations, including medically complex, trauma history, mental health conditions, substance abuse, and socioeconomic barriers in an office or community-based setting. Preference given to qualified candidate with multiple settings experience (Inpatient, LTPAC, home health, corrections, community programs and/or human service agencies.).
• Experience with complex government-sponsored populations preferred, e.g., Medicaid, Medicare beneficiaries.
• Experience with member engagement, transitions of care, clinical care, and/or case management.
• Must be willing to travel to meet the member where they are and support their care including specialist offices, outpatient centers, dialysis centers.
• Excellent computer skills including Microsoft Office Suite (Outlook, Excel, PowerPoint, Word) and electronic medical record documentation required.
• Excellent written and oral communication skills to interact with members, families, community stakeholders, and interdisciplinary team required.
• Ability to meet accreditation and quality standards including, but not limited to NCQA, PCMH, HEDIS through following defined procedures to assess, intervene and document interactions.
• Ability to work independently and exercise excellent clinical judgement.
• Hold and maintain active driver’s license and proof of insurance in state of practice.