Position Description Base pay is influenced by several factors including a candidate’s qualifications, relevant experience, and anticipated contributions to meet the needs of the business, along with internal pay equity and external market driven rates. The salary range displayed has not been adjusted for geographical location. This range has been created in good faith based on information known to Capital Blue Cross at the time of posting and may be modified in the future. Capital Blue Cross offers a comprehensive benefits packaging including Medical, Dental & Vision coverage, a Retirement Plan, generous time off including Paid Time Off, Holidays, and Volunteer time off, an Incentive Plan, Tuition Reimbursement, and more. At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it’s why our employees consistently vote us one of the “Best Places to Work in PA.” The Care Manager is responsible for the coordination of services for members who meet established criteria, with an emphasis on education/self-management and promoting quality care and cost-effective outcomes. The Care Manager uses a collaborative process to assess Member needs, review options for services and resources, develop and implement a plan of care, coordinate resources, monitor progress, evaluate Member status, discharge Members, and fully document the individualized member care management process and outcome. The care manager will address, medical, psychosocial, clinical needs, and behavioral health needs including members with mental health and substance use disorder needs. Care Managers provide counseling and referrals to community/local/state programs; collaborate with caregivers, providers, community agencies, behavioral health, and other resources to coordinate care to achieve member’s optimal health status. The Care Manager is responsible for the management and oversight of a caseload of moderate - high risk Members with complex medical/behavioral /psychosocial needs. Responsibilities and Qualifications Uses a collaborative process and serves as a liaison between the participant, family and significant others, behavioral and medical physician(s) and other members of the treatment team. Develops prioritized goals and health actions that assist participants with the implementation of appropriate self-directed care decisions and support improvement in health and self-reliance. Advocates for members and families by helping them to coordinate care and navigate resources to reduce barriers and meet healthcare needs. Analyzes and evaluates referrals for potential enrollment of Members into Care Management Program(s) using established criteria. Conducts assessments to obtain information for a participant-centered plan of care and determination of acuity level, functional status, psychosocial status, and barriers. Obtains consent forms necessary for candidates accepted into the Care Management Program. Applies established criteria for discharge and discharges the Member from the Care Management Program(s) when the criteria are met. Conducts all care management activities, including documentation, in accordance with established departmental policies and procedures. Complies with all Clinical Management and corporate policies and procedures. Builds relationships with members, their families, and implements interventions that move assigned members toward goals of improved knowledge, self-management, and long term care outcomes of stabilization. Identifies and reports quality of care issues in accordance with established departmental policies and procedures. Maintains member confidentiality at all times. Attends company and departmental meetings and training sessions as required. Skills Strong communication skills and the ability to positively interact with customers, peers, leadership, family members, caregivers, visitors, contracted agencies/personnel and the general public. Superior clinical process, critical thinking, and problem-solving skills; and ability to handle critical situations. Excellent written, oral communication, listening, and organizational skills. Ability to use computer system while conversing telephonically Able to demonstrate strong customer service skills, including tact and diplomacy, both in person and telephonically when communicating with internal and external customers Ability to appropriately prioritize workload and assignments and perform accurate, detailed and timely completion of assigned duties. Ability to work autonomously and as part of an interdisciplinary team Demonstrates sound judgment that affirms the rights and responsibilities of Member’s, families, health care professionals and health care organizations. Ability to operate a personal computer (PC), including proficiency in Microsoft Office Products. Knowledge Knowledge of NCQA standards for Population Health Management for health plan accreditation, DMAA standards for disease management and CMSA Standards of Practice for Case Management, Act 68, CMS and ERISA. Maintains knowledge of evidence-based guidelines for chronic conditions/care management. Knowledge of clinical and managed care principles and operations. Knowledge of current and emerging medical treatment modalities and best practice guidelines with the ability to analyze and interpret medical and benefit coverage interrelationships. Knowledge of adult learning principles, motivational interviewing, and intrinsic coaching techniques. Experience At least three (3) years’ recent/related experience; care management, home health, medical/surgical behavioral health, and/or critical care preferred. Health plan experience preferred Experience related to Oncology highly preferred. Experience in health coaching and motivational interviewing techniques preferred. Education and Certifications Registered Nurse with active licensure in home state; additional state’s licensure as needed/required to meet customer needs Certified Case Management certification within 2 years of employment. Physical Demands Ability to travel to provider, facility, employer group and/or member locations using own vehicle, if appropriate. About Us We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a caring team of supportive colleagues, and be encouraged to volunteer in your community. We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career. And by doing your best, you’ll help us live our mission of improving the health and well-being of our members and the communities in which they live. Apply To This Job