Outpatient Case Manager

About the role

The Outpatient Case Manager is responsible for intake and providing case management services for members with chronic medical conditions, and/or socioeconomic and mental health co-morbidities. The role involves assisting these members to achieve optimal health and/or independence in self-managing their care.

Responsibilities

• Conducts health risk assessments, including physical, functional, social, psychological, environmental, learning, and financial needs of the member.
• Identify problems, goals, and interventions to meet members’ needs, including prioritized goals that are preferred by member and caregivers.
• Create an individualized care plan with the member, caregiver, and the member’s PCP to include short/long-term goals and interventions.
• Provide appropriate interventions that demonstrate knowledge and sensitivity toward cultural diversity and religious, developmental, health literacy, and educational backgrounds of the population served. Use interpreter services as needed.
• Evaluate member’s progress toward goal achievement, including identification and evaluation of barriers to meeting member’s needs. Reassess for changes in goals and /or health status.
• Conduct an ICT meeting to communicate with PCP and members of the interdisciplinary care team about the care plan and the member’s status.
• Knowledge and experience managing and evaluating HRA cases.
• Act as a member advocate and assist with problem-solving and addressing any barriers to care needs.
• Cook up and refer to appropriate community resources; facilitate access and communication when multiple services are involved.

Requirements

• 2+ years of nursing experience in an acute care hospital setting
• 1+ years of managed care and utilization review experience
• Experience in CMS and MCG
• Experience with clinical review
• Clinical knowledge of chronic conditions, such as diabetes and congestive heart failure
• Strong written and verbal communication skills with patients, physicians, and other stakeholders
• Demonstrated ability to assess and respond to patient and family needs in a timely manner
• General knowledge of case management practices, including familiarity with relevant products and services