Care Manager (Hybrid)

PURPOSE :

Under minimal supervision, the Care Manager researches and analyzes a member's medical and behavioral health needs and healthcare cost drivers.

The Care Manager works closely with members and the interdisciplinary care team to ensure members have an effective plan of care and positive member experience that leads to optimal health and cost-effective outcomes.

We are looking for an experienced professional in the Washington DC area who is willing and able to work in a hybrid model.

The incumbent may be dedicated to a particular region or hospital system. The incumbent will be expected to work a portion of their week from home or other member / provider related location (such as a provider office or hospital system location) and a portion of their week at a CareFirst location based on business needs and work activities / deliverables that week.

Must have a DC RN licensure.

ESSENTIAL FUNCTIONS :

Identifies members with acute / complex medical and / or behavioral health conditions. Engages onsite and / or telephonically with member, family and providers to develop a comprehensive plan of care to address the member’s needs at various stages along the care continuum.

Identifies relevant CareFirst and community resources and facilitates program, network, and community referrals.

Collaborates with member and the interdisciplinary care team to develop a comprehensive plan of care to identify key strategic interventions to address member’s medical, behavioral and / or social determinant of health needs.

Engage members and providers to review and clarify treatment plans ensuring alignment with medical benefits and policies to facilitate care between settings.

Monitors, evaluates, and updates plan of care over time focused on member's stabilization and ability to self manage. Ensures member data is documented according to CareFirst application protocol and regulatory standards.

QUALIFICATIONS :

Education Level : High School Diploma or GED

Licenses and Certifications

• RN - Registered Nurse - State Licensure And / or Compact State Licensure RN- Registered Nurse in MD, and Washington, DC
• Accredited Case Manager (ACM) Federal Employee Program Book of Business (ONLY) : Must have CCM / ACM or other RN Board Certified certification in case management.

Incumbents not certified at the time of hire must have two years of case management experience and meet requirements to take CCM or ACM exam and successfully achieve the certification within the first year of employment OR

CCM - Certified Case Manager Federal Employee Program Book of Business (ONLY) : Must have CCM / ACM or other RN Board Certified certification in case management.

Incumbents not certified at the time of hire must have two years of case management experience and meet requirements to take CCM or ACM exam and successfully achieve the certification within the first year of employment.

Experience : 5 years clinically related experience working in Care Management, Discharge Coordination, Home Health, Utilization Review, Disease Management or other direct patient care experience.

See additional information below if Care Manager position is behavioral health focused.

Preferred Qualifications

• Bachelors degree in nursing
• CCM / ACM or other RN Board Certified certification in case management. Federal Employee Program (FEP) Book of Business (ONLY) : Must have CCM / ACM or other RN Board Certified certification in case management.

Incumbents not certified at the time of hire must have two years of case management experience and meet requirements to take CCM or ACM exam and successfully achieve the certification within the first year of employment.

Knowledge, Skills and Abilities (KSAs)

• Knowledge of clinical standards of care and disease processes.
• Ability to produce accurate and comprehensive work products with minimal direction.
• Ability to triage immediate member health and safety risks.
• Basic understanding of the strategic and financial goals of a health care system or payor organization, as well as health plan or health insurance operations (e.

g. networks, eligibility, benefits).

• Excellent verbal and written communication skills, along with the telephonic and keyboarding skills necessary to assess, coordinate and document services for members.
• Knowledgeable of available community resources and programs.
• Proficient in the use of web-based technology and Microsoft Office applications such as Word, Excel and PowerPoint.
• Ability to provide excellent internal and external customer service.
• Must be able to effectively work in a fast-paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time.

Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence.

Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.

Additional Skills and Abilities

For Behavioral Health Care Managers, must have the following Education, Experience and License(s) :

Must be licensed in at least one of the three states and / or jurisdictions shown below and have the ability to meet credentialing requirements for independent professional practice (Masters

level licensed behavioral health professional) :

• Maryland : LCSW-C or LCMFT or LCPC
• Washington, DC : LICSW or LPC or LMFT
• Virginia : LCSW or LPC or LMFT
• Master’s degree in Mental Health field required; education can be in one or more of the following areas : Social Work, Psychology, Nursing or Counseling.
• Minimum 5 years post masters clinical behavioral health / psychiatric experience required.
• Effective application of best clinical practices.
• Solid understanding of behavioral health diagnoses.
• Knowledge of mental health and substance use community resources and providers.
• Knowledge of DSM V or most current diagnostic edition.

Department

Department :

Equal Employment Opportunity

CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.