Virginia Premier Health Plan, Inc.

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Care Manager II - Medicare Advantage

Care Manager II - Medicare Advantage

Job Locations 
US-VA-Glen Allen
Job ID 
2017-4215

Job Description

Overview

Under the supervision of the Manager, Care Managers provide primary case management and care coordination services to members who have less complex medical and/or behavioral health needs as part of VPHP’s MAPD CM program. These case managers focus on moderate to high risk Medicare Advantage enrollees who are may be at risk for higher utilization of services, readmissions, and/or transitions. This role involves telephonic interactions to provide the support needed for ongoing care coordination to enhance quality, improve member outcomes, and encourage appropriate utilization of health services.

 

Medical Management

Medical Management educates members and empowers them to become active participants in their coordinated health care plans.  This team of knowledgeable professionals in their field provide services to include Utilization Review, Medical Outreach, Case Management, Disease Management, Credentialing, Social Work as well as Grievance and Appeals

 

Responsibilities

  • Provides primary case management to members with less complex medical and/or behavioral health needs who are part of the MAPD CM program
  • Conducts assessment of the member’s medical and behavioral health, psychosocial needs, functional status, and social history and develops person-centered care plan collaboratively with the member, family, caregiver, and PCP
  • Conducts triggering assessments and updates to the care plan with the member, family or caregiver, and PCP/provider to maximize health care responses, quality and cost-effective outcomes
  • Conducts annual reassessments with the member with an updated care plan
  • Facilitates communication and coordination between members of the health care team
  • Educates the member, the family or caregiver, and members of the health care team about treatment options, community resources, insurance benefits, psychosocial concerns, case management , etc., so that timely and informed decisions can be made.
  • Assists the member and their family/caregiver in navigating the health care system
  • Encourages the member to be actively involved in the health care decision-making process
  • Empowers the member to problem solve by exploring options of care, when available, and alternative plans, when necessary, to achieve desired outcomes
  • Encourages the appropriate use of health care services and strives to improve the quality of care and maintain cost effectiveness on a case-by-case basis.
  • Collaborates with UR nurse to manage length of stay based upon medical necessity, community supports, and member’s specific social situation.
  • Provides referrals for brief and immediate crisis intervention (i.e. Adult Protective Services).
  • Provides referrals to health-related services such as disease management and health education
  • Strives to promote member self-advocacy and self-determination
  • Acts as an advocate for a member’s health care needs
  • Participates in VPHP’s ongoing quality improvement process
  • Participates in continuing educational activities as appropriate
  • Participates in case management rounds/meetings
  • Practices in accordance with applicable local, state and federal laws which govern confidentiality and medical information privacy regulations (HIPAA)

Qualifications

MINIMUM EDUCATION REQUIREMENTS

  • Registered Nurse licensed in the Commonwealth of Virginia
  • Bachelor degree in a health-related field preferred
  • Certified Case Manager preferred 

SPECIAL KNOWLEDGE AND/OR SKILLS

  • Knowledge of Medicare program
  • Proficient use of Microsoft Office and various computer software programs
  • Working knowledge of resource options, and experience in making appropriate referrals
  • Strong decision making skills, ability to handle multiple priorities

WORK BACKGROUND/EXPERIENCE

  • Minimum of 2 years clinical experience working with the frail and elderly, disabled populations
  • Previous work experience with behavioral health populations is needed
  • Knowledge of community resources preferred.

PHYSICAL REQUIREMENTS

  • Physical health sufficient to meet the ergonomic standards and demands of the position.

About Us

Virginia Premier Health Plan, Inc. is a managed care organization which began as a full-service Medicaid MCO in 1995. Partnered with VCU Medical Systems we strive to meet the needs of the underserved and vulnerable populations in Virginia by delivering quality driven, culturally sensitive and financially viable Medicare and Medicaid healthcare programs.  Headquartered in Richmond, VA we also have offices in Roanoke, Tidewater and Bristol with additional satellite locations allowing us to serve over 200,000 members across eighty counties throughout Virginia. 

 

We offer competitive salaries and a comprehensive benefits package to include excellent Medical, Dental and Vision Plans, Tuition Assistance, Infant-At-Work Program, Remote Work options and generous vacation and sick leave policies. Our culture supports an environment where employees can continuously learn and gain professional growth through various development programs, education, exciting projects and career mobility.  

 

All qualified applicants will receive consideration for employment without regard to age, race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status. EOE

 

Our mission is to inspire healthy living within the communities we serve!

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