Case Manager - CM

Health New England
US - Massachusetts - Springfield
January 7, 2025

SUMMARY:
The Case Manager - CM is responsible for delivering case management (CM) and disease management (DM) services to members in compliance with current accreditation requirements and quality standards, and within the scope of the members' benefit package and per HNE policies.
This position may also provide prospective discharge planning and care transition management for members in acute care and skilled nursing facilities (SNF) through collaboration with members and their support systems, inpatient and outpatient providers to ensure a safe and effective discharge.
Assess plans and evaluate all options and services to provide quality, efficient, and cost-effective healthcare services to HNE members.
Ensure evidence based clinical guidelines, preventive guidelines and protocols are incorporated into member-centric treatment plans.
Refer and/or enroll members into health plan and office based complex case management or disease management programs.
Support the HNE mission by developing partnerships with and providing personal and accountable service to members and providers.
Impact positive health outcomes for members and positive financial outcomes for HNE.
Keep abreast of professional standards, new technologies and proactively seek out new learning.

ESSENTIAL FUNCTIONS:

CM/DM functions:

Outreaches to and assist members with chronic health conditions, catastrophic illness, and complex healthcare needs.
Conducts face-to-face or telephonic case management and/or disease specific assessments-and develop individualized care plan including setting short- and long- term goals.
Provides ongoing health coaching and support, self-management education, condition specific education, care coordination, and resources and materials.
Effectively utilize health behavior change techniques including Motivational Interviewing.
Assists members and providers with transition of care, referral management, care coordination, and benefit management through:
Identification of appropriate utilization and high quality provision of post-acute, sub-acute or skilled nursing facility levels of care including but not limited to acute rehabilitation, skilled nursing services, home care and/or community services
Assessment, implementation, coordination and evaluation of options and services needed to meet the member's health needs across the care continuum
Communication with internal and external partners including but not limited to hospital partners, ACO practice based care managers and providers.
Provision of case management activities across the continuum of care in order to facilitate and promote high quality, and cost effective outcomes.
Collaboration with the member's support network, treating provider(s), utilizing a multi-disciplinary approach to assess, identify, plan and measure outcomes.

Other essential functions:
Contributes to enhancement of services -existing and new- by participating on work groups, clinical initiatives, service initiatives, quality initiatives, and others as assigned.
Makes appropriate referrals within CSI team and external resources, such as a members and providers to maximize positive member outcomes as per HNE policies and processes.
Assists with creation and revision of departmental Policy & Procedures.
Participation with off-site visits to in-plan facilities and provider
Effectively utilizes HNE UM/CM/DM policies and processes, and electronic systems.
Adheres to departmentally established productivity standards.
Maintains collaborative and helpful working relationships with CSI team and other departments.
Participates in the On-call program as well as flexible work hours as needed within the department.
MINIMUM REQUIREMENTS:

Associates degree in nursing (Bachelor's degree preferred) and a current license as a Registered Nurse with 3 - 5 years' experience as a case/care manager, utilization management nurse, or health coach in managed care, home care, or hospital setting; or an equivalent combination of education and experience.
Experience in patient education working with individual patients required
CCM preferred
Knowledge of chronic health conditions preferred.
Must be self-starter willing to proactively seek out and learn about etiology, care and treatment for many health conditions.
Computer literacy and ability to navigate through computer systems required.
Excellent written and verbal communication skills including the willingness to deliver presentations.
Sound clinical assessment and decision-making skills, and highly ethical
Excellent critical thinking and organizational skills, with attention to detail.
Excellent time management skills and ability to manage multiple priorities.
Ability to work independently and manage an assigned caseload.
Strong teamwork skills; ability to work collaboratively and consultatively with team members.

WORKING CONDITIONS:
Works in a standard office-based environment

Read the full job description and apply online on the recuiter's web-site

Case Manager - CM

Case Manager - CM

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