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Job Summary

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This role is a member of the integrated community care team (ICCT), providing integrated case management for members with complex medical, behavioral, and social determinants of health needs. The CCM is assigned providers in the Community. Members are assigned to the CCM based health instabilities, utilization and healthcare spend. The CCM completes a comprehensive assessment and creates a person-centered care plan that identifies and prioritizes health care goals with the member. The CCM supports members meeting their goals through clinical interventions, education, motivational interviewing, self-management coaching and complex case management service including navigation of health plan benefits. The CCM coordinates the services with our community primary care providers, health plan programs, AbsoluteCare services, community resources, and specialists required to meet the member’s individual needs and meet value-based outcomes. The CCM meets members where they are conducting member visits in the home, community and/or office setting including the Comprehensive Care Center.

Job Summary

This role is a member of the integrated community care team (ICCT), providing integrated case management for members with complex medical, behavioral, and social determinants of health needs. The CCM is assigned providers in the Community. Members are assigned to the CCM based health instabilities, utilization and healthcare spend. The CCM completes a comprehensive assessment and creates a person-centered care plan that identifies and prioritizes health care goals with the member. The CCM supports members meeting their goals through clinical interventions, education, motivational interviewing, self-management coaching and complex case management service including navigation of health plan benefits. The CCM coordinates the services with our community primary care providers, health plan programs, AbsoluteCare services, community resources, and specialists required to meet the member’s individual needs and meet value-based outcomes. The CCM meets members where they are conducting member visits in the home, community and/or office setting including the Comprehensive Care Center.

Duties And Responsibilities

• Meet with community primary care providers on a regular basis and review assigned member care plans and ongoing health needs.
• Attend member visits at their primary care provider or specialist office appointments and provide follow-up support for care coordination needs.
• Complete comprehensive assessment and person-centered care plans (PCCP) for each member on the assigned caseload.
• Manage person-centered care plans and member contact in compliance with all agency requirements, internal protocols, and accreditation standards.
• Develop, implement, and maintain person-centered care plans using SMART goals.
• Maintain up to date PCCPs in the electronic health record, including objective measures to track progress required to successfully track and complete treatment plan goals.
• Provide education with teach back regarding medical, behavioral, and functional health conditions, symptoms, and treatment options.
• Provide evidence-based clinical interventions centered on established person-centered care plan goals using a variety of approaches, e.g., trauma informed care, harm reduction, behavior change modalities, motivational interviewing, teach back methods and problem solving.
• Meet established Key Performance Indicators.
• Manage assigned caseload based on contact frequency requirements and utilization data.
• Proactively mitigate/resolve barriers to care to increase adherence to treatment plan.
• Collaborate with the ICT to update the team on member progress and needs and provide CCM recommendations for members to stabilize health and overcome barriers to social determinants of health.
• Assist members in accessing and engaging with services and resources.
• Maintain schedule in the clinical system and document all interactions within 1 business day.
• Actively participate in required meetings.
• Follow up on member compliance to service or resource referrals.
  
  

Minimum Qualifications

• Must be willing and able to travel up to 80% of the time to member homes, member appointments at healthcare facilities and provider offices and/or other sites within local communities.
• Licensed clinician (RN, LCSW, LMSW, LMHC, LPC) by the state in which practicing and abide by all laws, regulations, and requirements. Preference given to qualified case managers with CCM credentials. CMGT-BC, CCTM, C-SWCM, C-ASWCM, ACM or FAACM will be considered.
  • Preference will be given to RN or licensed clinician with extensive experience in chronic condition and medical case management in the community.
  • In lieu of CCM credential, 3+ integrated case management experience. Must obtain CCM within 24 months of hire date.
  • Active CPR certification.
• 3+ years of experience in serving the needs of complex populations, including medically complex, trauma history, mental health conditions, substance abuse, and socioeconomic barriers in an office or community-based setting.
  • Preference given to qualified candidate with multiple settings experience (Inpatient, LTPAC, home health, corrections, community programs and/or human service agencies.)
  • Experience with complex government-sponsored populations preferred, e.g., Medicaid, Medicare beneficiaries
  • Experience with member engagement, transitions of care, clinical care, and/or case management
• Must be willing to travel to meet the member where they are and support their care including specialist offices, outpatient centers, dialysis centers.
• Excellent computer skills including Microsoft Office Suite (Outlook, Excel, PowerPoint, Word) and electronic medical record documentation required.
• Excellent written and oral communication skills to interact with members, families, community stakeholders, and interdisciplinary team required.
• Ability to meet accreditation and quality standards including, but not limited to NCQA, PCMH, HEDIS through following defined procedures to assess, intervene and document interactions.
• Ability to work independently and exercise excellent clinical judgement.
• Active unencumbered driver’s license, with automobile insurance, reliable transportation, and ability to work in office and in the community.
• Hold and maintain active driver’s license and proof of insurance in state of practice.
  

Working conditions

This job operates in the community and within a professional office environment. This role requires reliable transportation to commute back and forth between member homes and office; and routinely uses general office equipment.

Physical Requirements

• Ability to communicate clearly and exchange accurate information constantly.
• Ability to remain stationary for long periods of time.
• Constantly operates computer, keyboard, copy and fax machine, phone, and other general office equipment.
• Operates a personal motor vehicle.
• Ability to occasionally move objects up to 20 lbs.
  
  

Direct reports

None.Seniority level

• Seniority levelMid-Senior level

Employment type

• Employment typeFull-time

Job function

• Job functionHealth Care Provider
• IndustriesHospitals and Health Care

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