Care Manager
3 weeks ago
It’s an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.
The Clinical Care Manager will perform as a Lead Care Manager responsible for the overall local integrated, holistic person-centered care management interventions for a member’s physical health, behavioral health (BH) and psychosocial support needs. The Clinical Care Manager will perform a variety of diverse and complex face-to
Our Investment in You:
- Full-time remote work
- Competitive salaries
- Excellent benefits
**Key Functions/Responsibilities**:
- Manages a panel of high risk, medically, behaviorally and socially complex members
- Administer Comprehensive Assessment, medication reconciliation, convene local care teams, develop, document, and implement integrated care plans Completes timely initial and on-going face-to-face comprehensive assessments with Member to evaluate member’s medical, behavioral health, functional status, and socioeconomic needs
- Collaborates with Members of the local care team, including community/state agencies and internal staff
- Develops and communicates an Individual Plan of Care (IPC) with member, caregiver(s), providers and other ICT members to address identified needs and ensures its implementation
- Evaluates the effectiveness of the IPC and progress against goals Utilizes evidence-based guidelines to assist member in understanding their disease process and increase their capacity for self-management and optimal health
- Utilizes data to ensure that clinical interventions result in improved clinical outcomes and appropriate utilization of services at the right time, right place, and right setting
- Evaluates the effectiveness of alternative care services and ensures that cost effective, quality care is maintained according to standards
- Provides pro-active management and follow up (via home visits, telephone, etc.) of the Member’s individualized plan of care (IPC)
- Facilitates member and caregiver access to community resources relevant to the member’s needs
- Documents clinical assessments and coordination of care in the medical management information system in a timely manner that meets regulatory and accreditation standards
- Collaborates with discharge planning staff at contracted hospitals, proactively anticipating member needs and preferences
- When designated as Lead Care Manager will lead discharge planning meetings, either in-person or telephonically
- Provides culturally competent care coordination in keeping with the Member’s racial, ethnic, linguistic and sexual orientation
- Facilitates sharing of essential clinical or psychosocial information related to the member’s care
- Be knowledgeable of the contractual requirements of the Care Management agreement with DHHS and contracted vendors and community agencies
- Adhere to Company and Department Policies and Procedures as well as State Contractual Requirements
- Maintain HIPAA standards and confidentiality of protected health information
- Reports critical incidents and information regarding quality of care issues
- Serves and participates in pertinent committees and meetings as needed
- Other duties as assigned
**Q**ualifications**:
- Active, unrestricted, Registered Nurse license required (NH or MA depending on service area)
- Bachelor’s degree in nursing or Associate’s degree in Nursing and relevant work experience
- 3 years clinical experience working with people who have multiple, chronic or complex health conditions in an acute care or health insurance environment
- 2 years of experience in care management, care coordination and/or discharge planning
- Commission for Care Manager (CCM) certification preferred
- Prior work with Medicaid population preferred
- Bilingual preferred
- Work is will be performed in the field as well as some home/corporate office work
**About WellSense**:
WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances.
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