Complex Case Manager

About Us

Community Health Choice, Inc. (Community) is a non-profit Managed Care Organization (MCO), licensed by the Texas Department of Insurance. Through its network of more than 10,000 providers and 94 hospitals, Community serves over 400,000 members with the following programs:

• Medicaid State of Texas Access Reform (STAR) program for low-income children and pregnant women
• Children's Health Insurance Program (CHIP) for the children of low-income parents, which includes CHIP Perinatal benefits for unborn children of pregnant women who do not qualify for Medicaid
• Health Insurance Marketplace Plans that offer individual health coverage including preventive care, emergency services, prescription drugs, and hospitalization available to all, regardless of pre-existing conditions
• Community Health Choice (HMO D-SNP), a Medicare Advantage Dual Special Needs plan for people with both Medicare and Medicaid that combines Medicare Part A and Part B benefits, Medicare Part D prescription drug coverage, and Medicaid benefits with additional health benefits like dental, vision, transportation, and more

Improving Members' experiences is at the heart of every Community position. We strive every day to make sure that our Members have access to the high-quality health care they need and deserve. Community is accredited by URAC for its health plan operations. We offer care management programs for asthma, diabetes, and high-risk pregnancy. An affiliate of the Harris Health System (Harris Health), Community is financially self-sufficient and receives no financial support from Harris Health or from Harris County taxpayers.

About the Role

The Complex Case Manager (CCM) will identify, monitor, manage, and evaluate the delivery of health services to Community members with chronic, medically complex, or catastrophic conditions in both acute and non-acute settings. The CCM will coordinate care with the involvement of the member, their PCP, specialists, and other providers. The role involves identifying the most medically appropriate therapeutic interventions to maximize clinical outcomes for chronic, medically complex diseases with potentially catastrophic outcomes.

The CCM will perform telephonic assessments and create individualized plans of care and discharge needs assessments based on member needs, utilizing available benefits and resources. The CCM will authorize services for active members admitted to the case management program at all levels of care, including outpatient, inpatient, and transitional levels.

The CCM will ensure proper data entry of authorizations in the managed care platform and initiate the approval process for requested services/treatments using nationally recognized evidence-based clinical criteria and/or internal policies, protocols, and procedures. The role requires using nursing knowledge, critical thinking, and background to screen and review clinical information for the most appropriate service areas within Community, making referrals to community health workers, high-risk perinatal and disease management teams, as well as external resources.

The CCM will work closely with medical directors and refer requests that do not meet medical necessity criteria. The CCM will initiate requests for single case agreements and/or letters of agreement for members requiring out-of-network providers. The role includes meeting required performance and quality metrics and ensuring reviews are completed within established regulatory and state requirements.

Requirements

• Registered Nurse (RN) with a current unrestricted license in the state of Texas
• BSN preferred
• CCM certification required or must be obtained within 18 months of employment
• 5 years of clinical experience in an acute care setting preferred
• At least 2 years of insurance-related experience in a managed care environment
• Proficiency in Microsoft Office (Word, Excel, Outlook)
• Above-average verbal communication skills (heavy public contact)
• Strong analytical skills and familiarity with medical terminology
• Strong written and verbal communication skills
• Demonstrated ability to motivate others
• Use of a personal car is required

Schedule

Flexible