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Job Summary: The Health Services Member Care Manager is responsible for coordinating and managing the care of members enrolled in SECUR Health Plan. This role involves developing individualized care plans, conducting follow-up member visits, and ensuring members receive appropriate and timely care. The Member Care Manager will work closely with an interdisciplinary team, including the member’s Primary Care Provider, to provide comprehensive care and support to members of SECUR Health Plan. The role is member-facing, and the candidate will spend 90-95% of their work time in the field, directly interacting with members to provide care and support. In this role, the Health Services Member Care Manager must assess and make appropriate recommendations regarding the types of care and services that the member requires to improve their health and quality of life. Thorough communication with the interdisciplinary care team is crucial to ensure that all member needs are met, and that care is coordinated effectively to achieve the best possible health outcomes.
Key Responsibilities:
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Health Risk Assessment (HRA): Completes initial and annual Health Risk Assessment (HRA) meeting all regulatory timeline requirements. Conducts comprehensive evaluation of potential health risks identifying exposure factors, analyzing data, and developing mitigation strategies to minimize health hazards in conjunction with the interdisciplinary team. This requires the RN to utilize their clinical expertise to identify subtle health risks and make informed decisions about the necessary interventions.
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Care Plan Development: Develops and updates Individualized Care Plans (ICP) based on HRA results and changes in members' medical needs. Incorporates the member's stated goals and desires to ensure that the care plan is personalized and aligns with their preferences and aspirations. The RN must use critical thinking skills to assess the member's condition, anticipate potential complications, and adjust the care plan accordingly.
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Member Follow-Up Visits: Conducts follow-up visits for members who have recently experienced post-acute discharges, falls, or have been assigned a risk score based on their most recent HRA. Conducts comprehensive assessments that include evaluating the member's clinical history, current medications, physical examination findings, psychosocial needs, functional status, and social determinants of health. The RN must make complex decisions regarding the member's care, considering multiple factors and potential outcomes.
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Care Coordination: Coordinates follow-up appointments, specialist visits, and other outpatient services for members. Partners with other members of the Health Services Department to stay knowledgeable of the latest member information. The RN must use their clinical judgment to prioritize care needs and ensure timely access to necessary services.
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Member Engagement: Conducts face-to-face visits with members to discuss care plans, assess progress towards goals, provide education, and ensure adherence to treatment. The RN must use their communication skills to effectively educate members and motivate them to adhere to their care plans.
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Collaboration: Works with the interdisciplinary team to address members' health concerns and ensure access to quality care. The RN must collaborate with other healthcare professionals, leveraging their expertise to provide comprehensive care.
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Documentation: Maintains accurate and timely documentation of all member interactions, care plans, and follow-up activities. The RN must ensure that documentation is thorough and reflects the member's condition and care plan accurately.
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Community Engagement: Engages with community partners and stakeholders to implement comprehensive health program initiatives. The RN must use their knowledge of community resources to connect members with additional support services.
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Preventative Health Initiatives: Assists in the design and implementation of preventative health initiatives and chronic care improvement programs (CCIP). The RN must use their clinical expertise to identify effective preventative measures and contribute to program development.
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Educational Materials: Assists in the design and distribution of educational materials and trainings for members and partners within the community to raise awareness regarding health risks and preventative measures. The RN must use their knowledge to create accurate and informative educational content that is consistent with the latest approved clinical best practices and industry standards.
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Compliance: Adheres to all federal, state, and accrediting body regulations, as well as SECUR Health Plan policies and procedures. Stays up to date on current compliance standards in terms of health and safety regulations, industry standards, and organizational policies. The RN must ensure that all care provided meets regulatory requirements and standards.
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Audits and Inspections: Assists in periodic audits and inspections to identify potential member non-compliance issues in facilities and promptly reports to leadership and members of the Interdisciplinary Care Team (ICT) for intervention. The RN must use their attention to detail to identify compliance issues and take appropriate action.
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Care Management and Chronic Condition Management Programs: Identifies, suggests, and collaborates with the interdisciplinary care team (ICT) on appropriate care management and chronic condition management programs that might benefit the member offered through SECUR Health Plan. The RN must use critical thinking and assessment skills to piece together data from various sources, aligning recommendations with the member's needs and ensuring they are enrolled in the most suitable care management program. This involves analyzing the member's health status, identifying potential gaps in care, and recommending programs that will enhance their overall health outcomes.
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Collaboration with Primary Care Physician: Collaborates with the Primary Care Physician on HCC gap closures, essential charting components, and the overall clinical picture of the member. The RN must use high-level problem-solving skills to understand and address HCC codes, ensuring that all gaps in care are closed and the member's clinical picture is accurately documented.
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All Other Duties as Assigned
Required Qualifications:
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Licensure: Active, unencumbered, unrestricted Registered Nurse (RN) license.
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Experience: Minimum of 2 years of experience in case management, care coordination, or a related field. This includes bedside and hands-on nursing experience with geriatrics, high-risk conditions, and other complex medical needs. The candidate must demonstrate proficiency in managing the care of elderly patients and those with chronic or high-risk conditions, utilizing their clinical skills to provide effective and compassionate care.
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Skills: Excellent communication skills, both written and oral. Strong organizational skills and the ability to manage time effectively. Ability to critically evaluate data, interpret findings, and draw meaningful conclusions.
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Team Collaboration: Ability to work collaboratively with an interdisciplinary team to provide comprehensive care.
Preferred Qualifications:
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Certifications: Certified Case Manager (CCM) or equivalent certification.
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Experience: Experience working with diverse populations, including those with chronic health conditions.
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Technology: Proficiency in using electronic health records (EHR) and care management software.
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Bilingual: Spanish fluency is preferred. The ability to communicate effectively with Spanish-speaking members is highly valued and will enhance the quality of care provided.
Reports To: Director of Health Services
Compensation Pay Range:
$76,133.58 - $118,958.71
This position requires consent to drug and/or alcohol testing after a conditional offer of employment is made, as well as on-going compliance with the Drug-Free Workplace Policy.
All Chapters Health System employees performing services for Florida affiliates are submitted through the Florida Care Provider Background Screening Clearinghouse to verify eligibility after a conditional offer of employment is made as well as ongoing eligibility. For more information, please visit https://info.flclearinghouse.com/.
