Position Summary:
The Care Manager Specialist is a member of the Care Team. The Care Manager Specialist is responsible for the care management of members that are enrolled in the Dual Special Needs Plan. These members are usually stratified as low - medium stratification, or those with Social Determents of Care needs. The Care Manager will work in conjunction with the Nurse Care Manager, Care Coordinator, Transition of Care (TOC) Coach, and other members of the Care Team to improve the member's health outcomes, address social determinants of health and connect members with community-based organizations. The Care Manager will assess member's needs as well as gaps in care, communicate with the member's Primary Care Provider (PCP), maintain updated individualized care plans, and participate in Interdisciplinary team meetings. Care Managers will be able to identify members whose needs require clinician involvement and transition members appropriately.
∙ Complete health screening questionnaires, assessments which may be market specific.
∙ Support reduction of population of unable to reach members by telephone and in -person visits.
∙ Ensure member has filled/received their medication(s) and has an understanding on how to take their ordered medications.
∙ Manage caseload of members with current stratification of monitoring, low and medium or those with high social determinants of care needs- frequency /contract guidelines
∙ Provides clinical assistance to determine appropriate services and supports due to member's health needs (including but not limited to: Prior Authorizations, Coordination with PCP and Specialty providers, Condition Management information and education, Medication management, Community Resources and supports)
∙ Evaluation of health and social indicators
∙ Identifies and engages barriers to achieving optimal member health.
∙ Uses discretion to apply strategies to reduce member risk.
∙ Presents cases at case conferences for multidisciplinary focus to benefit overall member management.
∙ Facilitates overall care coordination with the care team to ensure member achieves optimal wellness within the confines of the member's condition(s) and abilities to self-manage.
∙ Coordinates resources, assists with securing DME, and helps to ensure timely physician follow-up.
∙ Understands Payer/Plan benefits, policies, procedures, and can articulate them effectively to providers, members, and other key personnel.
∙ Updates the Care Plan for any change in condition or behavioral health status.
∙ Provide support to members in transitions of care.
