Care Manager, Complex & Disease Management - Emblem Health

• Provide care management, as part of a multi-disciplinary care team, that includes care coordination, performing telephonic or
face-to-face assessments of members' health care needs, identifying gaps in care and needed support,
administering/coordinating implementation of interventions.
• Support and enable members to manage their physical, environmental and psycho-social concerns, understand and
appropriately utilize their health plan benefits and remain safe and independent in their home or current living environment
in collaboration with health care providers.
• Provide Care Management services to identified high risk members within the community, including but not limited to
Physician Practices, Retail Centers/Neighborhood Care Centers, and members' homes.
• Coordinate and provide care that is safe, timely, effective, efficient and member-centered to support population health,
transitions of care, and complex care management initiatives.
• Engage with the most complex members of the health plan with the goal of improving health care outcomes and appropriate
and timely utilization of services across the continuum of care.
• Assist the entire Care Management interdisciplinary team in managing members with Care Management needs.

Principal Accountabilities

• Assess and evaluate the needs of our most complex members, acting as the clinical coordinator collaborating with
members, caregivers, providers, multi-disciplinary team, and health care and community resources through a variety of
assessments to identify areas of (medical, financial, environmental, health insurance benefit, psycho-social, caregiving)
concerns and potential gaps in care utilizing the most appropriate resources to support members' needs.
• Identify appropriate goals, strategies and interventions that may include referrals, health education, activation of
community-based resources, life planning, or program/agency referrals based on areas of concern.
• Develop, communicate and evaluate medical management strategies and interventions including potential for
alternative solutions to ensure high quality, cost effective continuum of care with the member, caregiver, provider(s)
and multidisciplinary team.
• Include member and family as appropriate.
• Engage actively with the member PCP / designee.
• Engage with the member in support of their treatment team to identify and establish attainable goals that positively
impact clinical, financial, and quality of life outcomes for member.
• Work collaboratively with all stake holders to ensure knowledge of the action plan, including participation in telephonic
and face-to-face case conferences when appropriate.
• Assess the needs of members and align them with the appropriate member of the care team (wellness team,
registered dietitian, social worker, community health workers).
• Act as the member's advocate and liaison by completing or facilitating interventions with providers and/or private,
non-profit, and governmental agencies.
• Ensure that all Care Management processes and reporting are compliant with all applicable federal and state
regulations, and NCQA and company standards.
• Participate in delegation collaboration activities, as required.
• Research evidence-based guidelines, medical protocols, provider networks, and on-line resources in making care
management recommendations.
• Enter and maintain documentation in the Electronic Medical Records System (EMR), meeting defined timeframes and
performance standards.
• Maintain an understanding of Care Management principles, program objectives and design, implementation,
management, monitoring, and reporting.
• Actively participate on assigned committees.
• Attend and complete all department-mandated training as well as satisfy educational in-service requirements.
• Perform other related projects and duties as assigned.
• Provide ongoing monitoring, evaluation, support and guidance to the coordination of the member's health care.
• Develop, implement and coordinate plan of care and facilitate members' goals. 10%
• Coordinate interdisciplinary team tasks and activities, with the goal of maintaining team performance and high morale.

Education, Training, Licenses, Certifications

• Bachelor's degree.
• RN required, with current active RN license.
• CCM certification preferred.
• Certification in utilization or care management preferred.

Relevant Work Experience, Knowledge, Skills, and Abilities

• 4 - 6 years of clinical experience.
• Organization/prioritization ability; and the ability to effectively manage a caseload of highly complex members.
• Support an integrated care model tapping into appropriate resources both internally and external to the organization.
• Experience in case management/care coordination, managed care, and/or utilization management. .
• Strong communication skills (verbal, written, presentation, interpersonal).
• Trained in the use of Motivational Interviewing techniques.
• Experience working in medical facility or practice and/or with electronic medical records.
• Computer proficiency: MS Office (Word, Excel, Powerpoint, Outlook); mobile technology (wireless phone/laptop, etc.)
• System user experience in a highly automated environment. .
• Bilingual ability (verbal, written).
• Strong cross-group collaboration, teamwork, problem solving, and decision-making skills.
• Ability to work a flexible schedule (evenings, weekends and holidays) to meet member and/or caregiver and departmental
scheduling needs.

Additional Information

• Requisition ID: 1000000413_01