Location: Raleigh, North Carolina US
Job Number: 1802
Position Title: Case Manager
Responsible for health care management and coordination within the scope of licensure for members with complex and chronic care needs by assessing, developing, implementing, coordinating, monitoring, and evaluating care plans designed to optimize member health care across the care continuum. Coordinates and monitors Alignment Healthcare member’s progress and services to ensure consistent cost effective care that complies with Alignment policy and all state and federal regulations and guidelines. Discharge planning from Hospital/SNF to home, hospital to SNF as needed. Performs duties mostly telephonically.
(May include but are not limited to)
- Ensures member access to services appropriate to their health needs.
- Identifies, assesses and manages members per established criteria.
- Develops care plans with member/caregiver/providers and works with member to accomplish goals
- Monitors and evaluates effectiveness of the care management plan and modifies as necessary.
- Measures the effectiveness of interventions to determine case management outcomes.
- Facilitates authorizations/referrals as appropriate within benefits structure or through extra-contractual arrangements.
- Uses independent judgment to determine appropriateness of such authorizations. Deploys internal and external resources to meet identified needs.
- Interfaces with Primary Care Physicians, Hospitalists, Nurse Practitioners and specialists on the development of care management treatment plans.
- Negotiates rates of reimbursement, as applicable.
- Assists with discharge planning for high risk population
- Assists in problem solving with providers, claims or service issues.
- Participates and provides feedback in the development of utilization/care management policies and procedures.
- Counsels and engages in personal discussions with patients and their families on available care options. Helps them to determine their appropriate and preferred course of action.
- Community resource knowledge
- Communication with multiple disciplines to provide the right level of care at the right time.
- Other duties based on supervisor request/need
- Minimum Experience:
- 3 years of clinical case management experience; or any combination of education and experience, which would provide an equivalent background.
- Requires a BA/BS in a health related field
- Current, unrestricted RN license in the state for which you are applying
Essential Physical Functions:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.
- The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.
State: North Carolina
Location City: Raleigh
Location State: North Carolina
Community / Marketing Title: Case Manager
Who is Alignment Healthcare?
- Socially responsible
- Technologically enabled
- Concierge care
- Servant leadership
We are dedicated to transforming the complex and confusing process of medical treatment in the United States so that every link in the health care continuum becomes more efficient, productive, and effective. We built a team of people who want to make a difference. Come join the team that is changing health care one person at a time.
We believe that great work comes from people who are inspired to be their best. We invite you to explore our wide variety of roles based on your unique experience.