Job Description

Role Overview:

The Care Manager is responsible for managing and coordinating care, services, and social determinants of health for medically fragile Members with acute, chronic, medically complex and/or behavioral health conditions and other health needs. Serves as the primary point of contact for the care team that includes Members, caregivers, physicians, and community supports to guide members in achieving their optimal level of health. Utilizes strong assessment and communication skills, critical thinking, and clinical knowledge to identify issues, gaps in care and barriers to care. The Care Manager develops a plan of care through shared decision making with the Member/caregiver and in collaboration with providers and other care team members to improve the Member’s health status, compliance with treatment plans and promote self-management. The Care Manager is also responsible for the following:

Responsibilities:

• Support Members during transitions of care through assessment, coordination of care, education of the discharge plan of care, referrals, and evaluation of the effectiveness of the plan. 
• Review medication list and educate Members with pharmacy needs, and counsel on side effects and mitigation strategies for specific treatment protocols.
• Evaluate, monitor, and update the care plan through regularly scheduled follow-up contacts based on the Member/caregiver progress, needs and preferences.
• Establishes points of contact in order to collaborate with identified community, medical, and/or behavioral health teams.
• Maintain timely, complete, and accurate documentation of Member interactions in ACFC electronic care management platforms where applicable.
• Monitor appropriate utilization and coordinate services with other payer sources, make appropriate referrals, identify and escalate quality of care issues.
• Develop a working knowledge of ACFC electronic care management platforms, care management programs, policies, standard operating procedures, workflows, Member insurance products and benefits, community resources and programs, and applicable regulatory, state, and NCQA requirements.
• May identify cases to be presented at care management rounds and follows 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.
• Face-to-face visits may be required at the Member’s residence, provider’s office, hospitals, other acute location or community location for education and/or assessment.

Work Arrangement:

· The candidate must live in MI.

• Valid driver’s license and car insurance. Must be willing to drive a personal vehicle for work related events/meetings.

Education/Experience

• Associate Degree in Nursing required. Bachelor of Science in Nursing preferred.
• 3+ years of clinical experience at the bedside (as a Registered Nurse) working with medically fragile patients in an acute care, home care, or special needs clinic.
• 3+ years of Case Management experience, preferably telephonic within a managed care organization, desired. 

Licensure:

• Valid driver’s license and car insurance. 
• Current and unrestricted Registered Nurse licensure. 
• Eligible to sit for Case Management certification after 12 months of employment. Must obtain this certification within 24 months of employment.

Skills & Abilities:

• Proficiency using MS Office (Word, Excel, Outlook, Teams), SharePoint, internet applications, and electronic medical record and documentation programs.
• Demonstrated proficiency working within a Windows 11 environment to include MS Office (Excel, Word, Outlook) and electronic medical record and documentation programs.

Your career starts now. We’re looking for the next generation of healthcare leaders.

At AmeriHealth Caritas, we’re passionate about helping people get care, stay well, and build healthy communities. As one of the nation's leaders in healthcare solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services, and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we’d like to hear from you.

Headquartered in Newtown Square, Pennsylvania, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.

Discover more about us at  . 

Our Comprehensive Benefits Package

Flexible work solutions including remote options, hybrid work schedules, Competitive pay, Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more.

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