Health Plan Care Manager

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

📋 Description

• Conduct thorough advanced-level nursing evaluations for both new and existing members, including targeted physical assessments for complex care and comorbidities.

• Deliver care management and coordination in accordance with CMSA standards and definitions, utilizing evidence-based criteria such as CMS and HEDIS quality measures.

• Oversee care within benefits frameworks and adhere to contractual, regulatory, and accreditation standards including DOD, CMS, URAC, and NCQA.

• Guarantee timely and precise member assessments, screenings, care transitions, encounters, follow-ups, and medical record documentation.

• Collaborate with primary care providers, specialists, medical directors, and community service organizations to meet member-centered needs.

• Engage, evaluate, educate, and support members, families, and caregivers concerning medical, health, social, psychological, environmental, and lifestyle matters.

• Record assessments, encounters, and other care management activities in the case management medical record.

• Ensure that written communications, member records, and forms are comprehensive, clear, organized, professional, and compliant with standards.

• Create and present case studies; participate in clinical rounds, in-services, staff education, and training sessions.

• Exhibit respectful, professional, and ethical customer service.

• Assist in process enhancements and support quality initiatives.

• Provide project assistance and fulfill additional tasks as necessary.

⛳️ Requirements

• A Bachelor’s degree in nursing is required.

• A Master's degree in nursing (MSN) is preferred.

• A minimum of 5 years of current clinical experience is required, ideally in medical-surgical, home care, hospice, community health, rehabilitation, long-term care, cardiovascular, diabetes, renal, pulmonary, oncology, or geriatric practice.

• Experience in a managed care, home health, or hospital setting is essential.

• An unrestricted state-licensed registered nurse license is required.

• Knowledge of the nursing practice scope in the states of licensure is necessary.

• Current clinical knowledge of chronic diseases, including heart disease, COPD, diabetes, renal disease, and other comorbidities is needed.

• Ability to apply sound judgment to recognize subtle changes and avert problems and complications.

• Must be a self-starter with high energy/productivity and a strong work ethic.

• Proven track record as a collaborative team player.

• Flexibility and adaptability in handling multiple priorities and shifting schedules.

• Exceptional written and verbal communication skills are required.

• Strong organizational and time-management abilities are essential.

🏝️ Benefits

• Medical insurance

• Dental insurance

• Vision insurance

• Retirement savings with employer contributions

• Paid time off

• Volunteer time off

• Pie day

• Other employee benefits