Lead Care Manager

The Lead Care Manager works closely with front line department employees and leadership to be the first-line contact person for Care Management program inquiries. The Lead Care Manager acts as a subject matter expert for the Population Health documentation platform, performs routine case audits and Care Manager duties. In addition, the incumbent will assist with process improvement and policy/procedure maintenance.

Job Responsibilities:

• Demonstrates commitment and behavior aligned with the philosophy, mission, values and vision of Network Health.
• Appropriately applies all organizational, regulatory, and credentialing principles, procedures, requirements, regulations, and policies.
• Assists in the development and implementation of policies, procedures, processes, materials, clinical guidelines, and documents for the care management program that comply with CMS, State of Wisconsin, NCQA, and other regulatory agencies. Assists the manager of care management in ensuring that standards are communicated to, and understood, by team members. Identifies gaps and works with department leadership to facilitate implementation of improved processes.
• First-line contact person to facilitates resolution of clinical care management issues.
• Acts as a subject matter expert for the Population Health documentation platform.
• Performs monthly and quarterly case audits.
• Assists in the monitoring of care management metrics that measure effectiveness and value of the case management programs.
• Maintains a member case load and performs core care manger role including but not limited to: screens candidates for case management, completes assessments, care plans with prioritized goals, interventions, and timeframes for reassessment using evidence-based clinical guidelines; evaluates and determines member needs based on clinical or behavioral information; updates care plan to reflect progress towards goals; closes cases when expected goals are achieved; provides information regarding case management activities to members, caregivers, providers and their administrative staff; evaluates and processes referrals; assess, plans facilitates and advocates for members to identify interventions services and resources to ensure health needs are met; works with members and families on self-management approaches; educates members, family and caretakers about case and condition management, the individuals' health condition(s), medications, provider and community resources and insurance benefits to support quality, cost effective health outcomes.
• Maintains current knowledge of State of Wisconsin, CMS & NCQA case management standards.
• Stays abreast of current best practices and new developments.
• Other duties as assigned.

Job Skills:

• Strong oral and written communication skills with the ability to listen mindfully, identify gaps and ask appropriate questions
• Strong critical thinking skills
• Ability to organize one's work and space to ensure successful completion of assigned tasks within the identified timeframe
• Ability to adapt to new circumstances, information and challenges in a fast-paced environment
• Ability to work independently, as well as part of a team in a remote capacity

Job Requirements:

• Bachelors of Science Degree in Nursing required or Social Work required.
• Master's degree in Social Work, preferred.
• Minimum of four (4) years clinical health care experience as a Registered Nurse (RN) or Social Worker.
• Minimum of two (2) years experience with Medicare, Medicaid, commercial fully insured, and/or self-funded populations required.
• Experience with Network Health business and processes preferred.
• Requires current registered nurse licensure in Wisconsin or currently licensed in the State of Wisconsin for Social Work (CSW, CAPSW or LCSW).

Candidates must reside in the state of Wisconsin for consideration. This position is eligible to work at your home office (reliable internet is required).

We are proud to be an Equal Opportunity Employer who values and maintains an environment that attracts, recruits, engages and retains a diverse workforce.