Health Plan Care Manager
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Job Description
Registered nurse managing complex member care for Martin’s Point Health Care, a Maine nonprofit providing care and health coverage. Coordinating providers, assessing members, and reducing unnecessary hospital utilization.
Responsibilities:
- Complete comprehensive advanced-level nursing assessments for new and existing members, including focused physical examinations for complex care and comorbidities
- Provide care management and care coordination according to CMSA standards and definitions, and apply evidence-based criteria such as CMS and HEDIS quality measures
- Manage care within benefits structures and comply with contractual, regulatory, and accreditation requirements including DOD, CMS, URAC, and NCQA
- Ensure timely and accurate member assessments, screenings, care transitions, encounters, follow-up, and medical-record documentation
- Collaborate with primary care providers, specialists, medical directors, and community service agencies to address member-centered needs
- Engage, assess, educate, and support members, families, and caregivers regarding medical, health, social, psychological, environmental, and lifestyle issues
- Document assessments, encounters, and other care-management activities in the case-management medical record
- Ensure written communications, member records, and forms are complete, clear, organized, professional, and compliant with standards
- Develop and present case studies; participate in clinical rounds, in-services, staff education, and training
- Demonstrate respectful, professional, and ethical customer service
- Assist with process improvements and support quality initiatives
- Provide project support and complete additional assignments as required
Requirements:
- Bachelor’s degree in nursing required
- MSN preferred
- 5 years of current clinical experience 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 environment
- Unrestricted state-licensed registered nurse license required
- Knowledge of the scope of nursing practice in states where licensed
- Current clinical knowledge of chronic diseases, heart disease, COPD, diabetes, renal disease, and other comorbidities
- Ability to use sound judgment to identify subtle changes and prevent problems and complications
- Self-initiator with high energy/productivity and a strong work ethic
- Proven history as a team player
- Flexibility and adaptability in managing multiple priorities and changing schedules
- Excellent written and verbal communication skills
- Excellent organizational and time-management skills
Benefits:
- Medical insurance
- Dental insurance
- Vision insurance
- Retirement savings with employer contributions
- Paid time off
- Volunteer time off
- Pie day
- Other employee benefits
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