Fidelis Care: Carer

Position Purpose: The Care Manager High Risk will be responsible for evaluating members risk adjustment, gaps in care, medication reconciliation, developing and updating an individualized care plan based on a comprehensive assessment of each member, while consulting with the member, their family/caregiver, and the assessment nurse.Implements the care plan and coordinate authorizations/arranges for delivery of covered services consistent with the care plan.Conducts ongoing home visits, communication and collaboration with member, family caregiver, or the member’s designated representative, as well as with member’s PCP, care team members, and other significant health care providers.Monitors provision of services by network providers across all health care settings to ensure they are appropriate and in accordance with the member’s care plan.Conducts ongoing monitoring of member’s health, safety, and functional status, and progress towards established goals.Provides coordination of care transitions, including discharge and transition planning from hospital or nursing homes, subacute, rehab, as well as care transitions in the home.Determines member eligibility for Fidelis services / programs and quality initiatives including Diabetes, CHF, CAD, ESRD, CPOD management program, falls prevention program, etc.Facilitates establishment of Advance Care Planning and assuring appropriate administration of the member’s Health Care Proxy.Reviews member’s medical status and issues, identifying follow up issues.Serves as primary contact with member’s PCP or specialist physicians as well as member’s long term care service providers.Monitors member’s medication adherence and gaps in care.Counsels member on his/her medical condition and provides education/coaching on self management or care giving by family members.Conducts CM level driven outreach visits/calls to each member to check on their progress status in relationship to member centric goals.Updates member case records / POC / Care Team recommendations to support optimal health.Participate in Quality Assurance and Improvement activities as directed by the Director of Care Management Medicare Pilot Program.Other duties as assigned by the Care Management Manager, Supervisor and/or the Director of Care Management.Education/Experience: BA/BS Bachelors Degree preferred.

Minimum 1-2 years Clinical experience.

Minimum 1-2 years experience in a Managed Care setting.

Knowledge of CMS: Medicare / Medicaid regulations.

Knowledge of evidence based guidelines (Milliman / Inter-qual a plus).

Experience in developing care plans.

Microsoft Office computer skills: Word, Excel & Care Management Software.

Proficiency in one or more languages other than English (Spanish, Cantonese, Mandarin).

Business Analysis Knowledge: Skilled to work in a fast paced environment.

Must have strong analytical and problem solving skills.

Customer Service: Skilled to communicate with all levels of management, internal and external customers.

Ability to work well as a member of a team or independently.

Effective Business Communication: Skilled in communicating with technical and business constituencies in writing effective business specifications and requirements.License/Certification: Active RN License required.

CCA Certification preferred.Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different.

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