ESSENTIAL FUNCTIONS AND RESPONSIBILITIES

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential functions.

* Provide members with transition of care calls to ensure that discharged members receive the necessary services and resources according to transition plan

* Conducts a transition discharge assessment onsite and/or telephonically to identify member needs at time of transition to a lower level of care

* Independently serves as the clinical liaison with hospital, clinical and administrative staff within our documentation system for discharge planning and/or next site of care needs

* In partnership with care team, make referrals to community sources and programs identified for members

* Engage member, family, and caregivers telephonically to assure that a well-coordinated action plan is established and continually assess health status

* Assess and identify the healthcare, educational, and psychosocial needs of the member and their family at the initial referral to care management

* Provide member education to assist with self-management goals, disease management or acute condition and provide indicated action plan

* Utilizing evidenced-based practice, develop interventions while considering member barriers independently

* Utilize motivational interviewing techniques to understand cause and effect, gather or review health history for clinical symptoms, and determine health literacy

* In consultation with manager of Care Management, conducts initial assessments within designated time frames for members identified as having Complex Case, Disease and Transitional Case Management needs (assessment areas include clinical, behavioral, social, environment and financial)

* Manages assessments regarding member treatment plans and establish collaborative relationships with physician advisors, clients, members, and providers

* Collaborates effectively with Interdisciplinary Care Team (IDCT) to establish an individualized transition plan and/or action plan for members

* Independently confers with UM Medical Directors and/ or Market Medical Directors on a regular basis regarding high-risk cases and participates in departmental huddles

* Ensure adherence to NCQA requirements for Complex Case Management

* Demonstrate understanding of utilization management processes

* Assists with data collection and closing of care gaps and quality metrics as assigned, and assists the healthcare team in meeting all of the quality metrics

* Maintain in-depth knowledge of all company products and services as well as customer issues and needs through ongoing training and self-directed research

* Manage assigned caseload in an efficient and effective manner utilizing time management skills

* Enters timely and accurate documentation into designated care management applications to comply with documentation requirements and achieve audit scores of 95% or better on a monthly basis

* Ensures licensure, certifications, and annual training are maintained and compliant

* Attends meetings and participates on committees as requested

* Identifies opportunities for process improvement in all aspects of member care

* Must maintain strict confidentiality at all times

* Must adhere to all department/organizational policies and procedures

* Performs all other related duties as assigned

Required Qualifications:

To perform this job successfully, an individual must have the following education and/or experience.

* Current, unrestricted RN license required, specific to the state of employment

* Expert knowledge of case management principles, as evidenced by certification in Case Management (CCM)

* Current certification as a Certified Case Manager or eligible for certification (https://ccmcertification.org/get-certified/certification/ccmr-eligibility-glance )

o If not yet certified at time of employment, must obtain certification within 12 months of date of hire

* 3+ years of diverse clinical experience; preferred in caring for the acutely ill members with multiple disease conditions (delegated medical management)

* 1+ years of managed care, Complex Case Management, Disease Management and/or Transitional Case Management experience

* Knowledge of utilization management, quality improvement, and discharge planning

* Knowledgeable in Microsoft Office applications including Outlook, Word, and Excel

Preferred Qualifications:

* Bachelor's Degree in Nursing

* Experience with Complex Case Management and DSNP NCQA requirements

* 3+ years of managed care, Complex Case Management, Disease Management and/or Transitional Case Management experience

* Ability to read, analyze and interpret information in medical records, and health plan documents

* Ability to problem solve and identify community resources

* Possess planning, organizing, conflict resolution, negotiating and interpersonal skills

* Independently utilizes critical thinking skills, nursing judgement and decision-making skills

* Able to prioritize, plan, and handle multiple tasks/demands simultaneously

Physical & Mental Requirements:

* Ability to lift up to 25 pounds

* Ability to sit for extended periods of time

* Ability to stand for extended periods of time

* Ability to use fine motor skills to operate office equipment and/or machinery

* Ability to receive and comprehend instructions verbally and/or in writing

Full COVID-19 vaccination is an essential requirement of this role. CareMount will adhere to all federal, state and local regulations as well as all client requirements and will obtain necessary proof of vaccination prior to employment to ensure compliance.

All qualified applicants will receive consideration for employment without regard to race, ethnicity, color, religion, sex, gender identity, sexual orientation, national origin, disability, or protected veteran status. CareMount is an EO employer - M/F/Veteran/Disability