- Continually assess and evaluate member and family needs utilizing strong communication skills, critical thinking, clinical knowledge, data, and tools.
- 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.
- 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.
- Collaborate within a team of professionals, including clinical utilization managers, account representatives, member service associates, dietitians, and physicians, to provide members with a high level of care coordination.
- 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.
- Identify cases to be presented at medical rounds and follow up with providers on recommendations to achieve optimal outcomes for members.
- Support a positive workplace environment, collaborate, and share clinical knowledge and skills to support our culturally and demographically diverse member population.
- Other clinical duties as assigned.
- 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.
- Ability to assess, analyze, draw conclusions, and construct effective solutions.
- Excellent written and verbal communication skills.
- Proficient with multiple IT systems.
- Able to identify and set goals, follow processes, meet deadlines, and deliver expected outcomes with the appropriate sense of urgency.
- Ability to interpret, evaluate, and document complex medical information to identify relevant and actionable conditions, circumstances, and behaviors.
- Demonstration of awareness, attitude, knowledge, and skills needed to work effectively with a culturally and demographically diverse population.
- Willingness to learn new business and clinical skills
- 3-5 years relevant experience in a variety of appropriate clinical health care settings (Inpatient, outpatient, or differing levels of care).
- Case Management experience preferred
- Certifications such as Case Management (CCM), certified diabetic educator, and Wellcoach certification a plus.
- Active licensure in Massachusetts is required, appropriate to position (RN, LMHC, LICSW, LCSW)
- Licensure in additional states a plus.
- Note: Any restrictions against a license must be disclosed and reviewed.
- For Registered Nurses Only: A Bachelor's degree in nursing (BSN) is preferred
- For Behavioral health position, a RN, LMHC, LICSW or LCSW is required
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Medicare Advantage Clinical Care Manager - Hingham, United States - BlueCross and BlueShield of Massachusetts
3 weeks ago
Description
Ready to help us transform healthcare? Bring your true colors to blue.The Role
The Clinical Care Manger 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.
The Clinical Care Manger will engage members in appropriate plans of care, coordinate care and services as appropriate, communicate effectively and provide members with education and resources as needed.
The Team
The Clinical Care Manger 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:
Key Qualifications:
Education and Experience:
Minimum Education Requirements:
High school degree or equivalent required unless otherwise noted above
Location
Hingham
Time Type
Full time
Hourly Range:
$ $49.53
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 employee's 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 Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law.
WHY Blue Cross Blue Shield of MA?
We understand that the confidence gap and imposter syndrome can prevent amazing candidates coming our way, so please don't hesitate to apply.
You might be just what we need for this role or possibly another one at Blue Cross Blue Shield of MA.
The more voices we have represented and amplified in our business, the more we will all thrive, contribute, and be brilliant.
We encourage you to bring us your true colors, , your perspectives, and your experiences. It's in our differences that we will remain relentless in our pursuit to transform healthcare for ALL.
As an employer, we are committed to investing in your development and providing the necessary resources to enable your success.
Learn how we are dedicated to creating an inclusive and rewarding workplace that promotes excellence and provides opportunities for employees to forge their unique career path by visiting our Company Culture page.
If this sounds like something you'd like to be a part of, we'd love to hear from you. You can also join our Talent Community to stay "in the know" on all things Blue.
At Blue Cross Blue Shield of Massachusetts, we believe in wellness and that work/life balance is a key part of associate wellbeing.
