Care Manager I, Specialty Programs

This is a fully remote position, open to applicants in New Jersey.

📋 Description

• Evaluate the clinical needs of members against established guidelines and standards tailored for specialty population-based members.

• Facilitate the provision of high-quality, cost-effective care following a personalized population model of care backed by clinical practice guidelines set forth by the plan.

• Collaborate with the member/family, healthcare providers, and all team members to ensure that the member's needs are effectively addressed, both within and outside the organization.

• Advocate for the member across various sites to coordinate resource utilization efficiently.

• Employ the care management process to prioritize, plan, organize, and execute interventions aimed at achieving self-care outcomes and transitioning to independent status.

• Ensure care for mandated non-compliant members by monitoring utilization closely.

• Accurately and comprehensively document according to practice standards and current organizational policies.

• Assess care through problem-solving, variance analysis, and participation in quality improvement initiatives to enhance member outcomes.

• Track member care activities, regardless of the service site or network participation, to ensure appropriateness and effectiveness of outcomes.

• Consult with internal stakeholders on complex cases and escalate issues to internal physician resources as necessary.

• Perform additional duties as assigned by management.

⛳️ Requirements

• Must possess a license as a Registered Nurse (RN) or hold a Bachelor's degree in social work, health, or behavioral science.

• A graduate-level degree in Social Work or Health and Behavioral Science is preferred.

• A minimum of three (3) years of experience working with members with special needs is required.

• Strong knowledge of case management practice standards is essential.

• Comprehensive understanding of managed care principles is required.

• In-depth knowledge of specialty populations, as applicable, is necessary.

• Excellent organizational skills are required.

• Strong oral and written communication skills are essential.

• Proficient PC skills and the ability to utilize Microsoft Office applications (Excel, Access, Word, etc.) are required.

• Effective problem-solving and conflict resolution skills are necessary.

• A valid New Jersey State License and insurance for certain positions is required.

🏝️ Benefits

• Comprehensive health benefits (Medical/Dental/Vision)

• Retirement Plans

• Generous PTO

• Incentive Plans

• Wellness Programs

• Paid Volunteer Time Off

• Tuition Reimbursement