SCOPE OF ROLE

The Case Manager III must be able to perform the functions of the Case Manager I and II. The role is accountable for promoting the quality, cost-effective outcomes for a population by facilitating collaboration and coordination across settings, assessing member needs, planning for care, monitoring the efficacy of interventions, and advocating to ensure member’s receive services and resources required to meet desired health and social outcomes. The role supports clinical leadership in ensuring the team meets productivity standards and adheres to the program structure.

ROLE RESPONSIBILITIES

• Able to perform the functions of the Case Manager II to include: assessment of the medical, social, and behavioral needs of an assigned population; Care Plan development and prioritization to transition members to optimal levels of health and self-management; Capacity to coordinate interdisciplinary team meetings; Collaboration across providers and healthcare settings to ensure optimal quality outcomes for an assigned population; Provide transition of care interventions as required; Facilitate care coordination, self-management planning, discharge planning, and health education for an assigned population; Facilitate linkage to appropriate community resources to address social determinants of health; Capacity to adjudicate referrals and apply evidence-based clinical criteria to coordinate member care needs across all care setting; Able to ensure member communication and notices are composed in a manner consistent with regulatory standards.
• Communicates to the team members daily/weekly/monthly regarding productivity and supports the team, when applicable, in meeting program outcomes
• Support clinical leaders in ensuring competency and consistency across programs; to include, conducting chart review, performing return demonstrations, and random audits based on performance
• Supports onboarding, training, and education across care teams
• Adheres to the Policies and Procedures set forth by the Quality Management Committee

EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE

• Associate’s degree in Nursing, Bachelor’s degree preferred
• Minimum 2 years of experience in medical management clinical functions.
• Training experience preferred
• Working knowledge of MCG, InterQual, and NCQA standards

LICENSURES AND CERTIFICATIONS

• Active and Unrestricted License as a Registered Nurse (RN)
• Certification in Case Management (CCM) or Managed Care Nursing (CMCN) preferred

PROFESSIONAL COMPETENCIES

• High level of critical thinking and problem-solving skills
• Strong work ethic and overall positive attitude
• Effective communication skills including verbal and written
• Ability to manage time effectively, understand directions, and work independently in a fast-paced environment
• Demonstrated flexibility, organization, and self-motivation
• Highly adaptable to change 

WORK ENVIRONMENT

• The majority of work responsibilities are performed in an open office setting, carrying out detailed work sitting at a desk/table and working on the computer.
• Some travel may be required.
• Ability to lift at least 50 pounds