RN Case Manager (Maternity)

Job Profile: RN Case Manager
Job Code: HCM410
Business Title: Clinical Care Manager, RN
Reports To: Clinical Manager Care Management

The Role
The Federal Employee Program Clinical Care Manager is responsible for facilitating care for members and families of members who may have rising health risks or complex healthcare needs, to promote optimal health.

This position is self-directed and works independently and collaboratively to facilitate care based on the principles of care management. Facilitation is focused on assessing needs, identifying health care disparities, social determinants of health, and any barriers to care.

The Team
The Clinical Care Manager is part of a highly dedicated and motivated team of professionals, including medical and behavioral health care managers, dieticians, pharmacist, clinicians, medical directors and more, who collaborate to facilitate care.

Key Responsibilities:

• Engage members in appropriate plans of care, coordinate care and services as appropriate, communicate effectively and provide members with education and resources as needed. Promote member compliance with treatment plan, encourage shared decision-making, and set appropriate goals to promote optimal member outcomes.

• Interpret and apply case management criteria, processes, policies, and regulatory standards to create, follow and appropriately document comprehensive care management plans.Interpret and apply case management criteria, processes, policies, and regulatory standards to create, follow and appropriately document comprehensive care management plans.

• Review medication list and educate members with complex pharmacy needs, and counsel on side effects and mitigation strategies for specific treatment protocols.

• Successfully connect, engage, and maintain member engagement to support seamless care transitions and optimized health outcomes.

• Interact with treatment providers, PCPs, physicians, therapists, and facilities as needed to gather clinical information to support the plan of care.

• Monitor clinical quality concerns, make referrals appropriately, identify and escalate quality of care issues.

• Understand member insurance products and benefits, as well as regulatory and NCQA requirements.

Key Qualifications:

• Ability to identify and document member-driven, specific, measurable activities that address actionable behaviors and goals

• Self-directed, independent, adaptive, flexible to change, and able to collaborate as a member of a team.
• Proficient with multiple IT systems.
• Demonstration of awareness, attitude, knowledge, and skills needed to work effectively with a culturally and demographically diverse population.
  

Education and Experience:

• 3-5 years relevant experience in a variety of appropriate clinical health care settings (Inpatient, outpatient, or differing levels of care).

• Maternal Health Experience, preferred

• Active licensure in Massachusetts is required, appropriate to position (RN/PT)

• Licensure in additional states a plus.

• Note: Any restrictions against a license must be disclosed and reviewed.

High school degree or equivalent required unless otherwise noted above

The job posting range is the lowest to highest salary we in good faith believe we would pay for this role at the time of this posting. We may ultimately pay more or less than the posted range, and the range may be modified in the future. An employees pay position within the salary range will be based on several factors including, but limited to, relevant education, qualifications, certifications, experience, skills, performance, shift, travel requirements, sales or revenue-based metrics, and business or organizational needs and affordability.

This job is also eligible for variable pay.

We offer comprehensive package of benefits including paid time off, medical/dental/vision insurance, 401(k), and a suite of well-being benefits to eligible employees.

Note: No amount of pay is considered to be wages or compensation until such amount is earned, vested, and determinable. The amount and availability of any bonus, commission, or any other form of compensation that are allocable to a particular employee remains in the Companys sole discretion unless and until paid and may be modified at the Companys sole discretion, consistent with the law.