TITLE: Care Manager
DEPARTMENT: Health Services
REPORTS TO: Director, Utilization Management
FLSA: Exempt

Position Summary: The Care Manager is responsible for managing members enrolled in the Disease/Case Management Program. Members in the program have been identified as having chronic and/or complex disease states. The Care Manager assumes a leadership role within the interdisciplinary team in order to achieve optimal clinical and resource outcomes. The Care Manager is responsible for assessing, planning, implementing, coordinating, monitoring, analyzing and evaluating of care plans, services and outcomes to maximize the health of members. The Care Manager is responsible for participating in the coordination of the Disease Management process along the continuum of care and functions as a resource for members, health plan staff, providers and community agencies. Program objectives and outcomes should include a fully integrated patient centered system. Outcomes will include physicians and patients actively partnering in all aspects of care. Decision making will be collaborative using evidence based medicine tools.

Essential Roles and Responsibilities:
I. Care Coordination and Management
  • Reviews patient records to identify necessary services, risk factors, and educational needs.
  • Completes an assessment and develops a care plan utilizing clinical expertise to evaluate the member’s candidacy for alternative services.
  • Coordinates and communicates care plan with the member’s Primary Care Physician and other members of the medical team.
  • Serves as a liaison and advocate between the member and their family, physicians, and health plan.
  • Develops strategies to address compliance issues for members at risk.
  • Provides member outreach.
II. Data / Outcomes Management
  • Evaluates the Disease/Case Management program on ongoing basis, reporting outcomes to the medical leadership team.
  • Monitors and evaluates member’s responses to interventions.
  • Utilizes existing IT technology to identify, track and trend members and outcomes. Develops additional assessment and tracking tools for Disease/Case Management program as necessary.
  • Monitors member’s and provider’s experience with the Disease/Case Management Program and communicates information as necessary.
  • Ensures integration of activities with other areas of the provider’s practice
Core Competencies:
  • Leadership: Shows ability to take action to “get things done”. Performs as a role model in meeting departmental standards. Able to influence the performance of others. Captures excitement and enthusiasm around a shared vision and department/company mission.
  • Communication: Maintains professional and positive interaction with physicians, offices, members and health plan staff. Presents information in a clear and concise format, ensuring mutual understanding through discussion, questions and feedback.
  • Customer Service: Exceeds internal and external customer expectations by demonstrating understanding of customer/member needs to ensure effective delivery of a solution, product, or service that best fits their needs.
  • Problem Resolution/Decision Making: Applies considered judgment to make decisions within assigned job duties, based on critical analysis and evaluation of the situation, the options, and their implications to elicit a positive outcome. Promotes dialogue to seek resolution of conflicts or problems with others. Seeks and offers solutions to problems.
  • Productivity: Effectively and efficiently uses time and resources to achieve work related goals, organizing activities according to priority and the need for coordination and cooperation with others.
  • Accountability: Takes responsibility for assigned work, following through to ensure goals are met or exceeded. Takes responsibility for decisions and/or actions in the job.
  • Responsiveness to Change: Demonstrates openness to new ideas and ways of working; adapts to changing needs and situations; approaches issues with an openness to change and a willingness to pursue different approaches to achieve a positive outcome.
  • Teamwork: Works cooperatively and collaboratively with others, contributes to the “team” in its broadest sense; encourages participation, commitment, and an active contribution from him/herself and others in the pursuit of common goals. Actively seeks ways to apply knowledge and skills to help others.
  • Technical: Demonstrates the ability to utilize medical necessity criteria, scope of benefits, health plan criteria and Medical Director Leadership appropriately; possesses average to excellent typing skills. Demonstrates CPT and ICD-9 coding familiarity. Demonstrates knowledge of Microsoft Office (Word, Excel, PowerPoint)
Other Duties and Responsibilities:
  • Performs other duties as assigned by the Health Services Department Leadership Team.
  • Provides required reports as indicated and participates in special projects as needed.
Knowledge, Skills, and Abilities:
  • Bi-lingual (English/Spanish) preferred
  • Ability to communicate effectively both orally and in writing
  • Cultural Sensitivity Required
  • Knowledge of Microsoft Office required
  • Typing ability required
Job Specifications:
  • Registered Nurse in the state of Illinois required
  • Bachelors Degree preferred
  • CCM certification preferred
  • Previous Call Center / Telephone Triage experience preferred
  • 3-5 years Managed Care/Case Management/Disease Management Required
  • 5+ years in varied direct patient care settings is required
  • Proficient computer skills and excellent telephone etiquette is mandatory
  • Must posses the ability to problem solve and utilize critical thinking skills