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Reporting to Manager of Care Management, the Care Manager will be an integral member of the health plan’s medical management team. This position is responsible for identifying and connecting high risk members to appropriate resources and programs to achieve optimal quality and financial outcomes. Responsibilities include managing and triaging self-referrals, identifying high risk members through HRA, reporting and admissions data, auditing patient charts of delegated case management programs to meet accreditation standards, and connect members with in-network providers and resources. This position is committed to the constant pursuit of excellence in improving the health status of the community.

MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Current Registered Nurse license issued by the state in which services will be provided or current multi-state Registered Nurse license through the enhanced Nurse Licensure Compact (eNLC).

EXPERIENCE:

1. Three (3) years of healthcare clinical experience.

PREFERRED QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Bachelor's Degree in Nursing OR Associate of Science in Nursing Degree (ASN); Currently enrolled in a BSN program and BSN completion within three (3) years of hire.

EXPERIENCE:

1. Management of Medicare and/or Medicaid populations.

2. Two (2) years Care Management experience.

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position.  They are not intended to be constructed as an all-inclusive list of all responsibilities and duties.  Other duties may be assigned.

1. Participate in activities related to care management program build, implementation, oversight, and delegation.

2. Perform utilization management reviews as needed according to accepted and established criteria, as well as other clinical guidelines and policies.

3. Manage and triage member self-referrals to care management programs.

4. Assist members in understanding their available medical benefits and connecting them with in network providers and community resources.

5. Identify barriers preventing the member from meeting maximum quality of life.

6. Review and Evaluate Health Risk Assessment (HRA) data to help drive development of programs and services geared toward member needs.

7. Review and Evaluate member outcomes data and work with other team members on performance improvement opportunities.

8. Utilizing NCQA standards in auditing processes of member records as part of care management oversight processes.

9. Investigating potential quality of care issues that may affect the quality or safety of the health of members.

10. May review medical records and other documentation to ensure quality care.

11. Assist in reviewing and updating activities and resources to address member needs.

12. Participate in case management and quality committees.

13. Assist in reviewing and updating policies and procedures to align with delegated processes.

14. Assist in quarterly reporting of delegated case management processes to meet accreditation standards.

15. Assist in submission of required documents/policies during application process to accrediting body.

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Standard office environment

SKILLS AND ABILITIES:

1. Working Knowledge of InterQual and/or Milliman Care Guidelines

2. Demonstrated knowledge of federal and state laws, NCQA and industry regulations related to disease management, utilization management, care management and discharge planning

3. Excellent written and oral communication

4. Problem solving capabilities to drive improved efficiencies and customer satisfaction

5. Attention to detail

6. Proficiency with Microsoft Office

Additional Job Description:

HYBRID (will be on-site Morgantown, WV)

Scheduled Weekly Hours:

40

Shift:

Exempt/Non-Exempt:

United States of America (Exempt)

Company:

PHH Peak Health Holdings

Cost Center:

2403 PHH Medical Management