Clinical Case Manager

Utilizes advanced clinical judgment and critical thinking skills to facilitate appropriate member physical health and behavioral healthcare through assessment and care planning, direct provider coordination/collaboration, and coordination of psychosocial wraparound services to promote effective utilization of available resources and optimal, cost-effective outcomes.

Fundamental Components & Physical Requirements

*Include but are not limited to:

Assessment of Members

• Through the use of clinical tools and information/data review, conducts comprehensive assessments of referred member’s needs/eligibility and determines approach to case resolution and/or meeting needs by evaluating member’s benefit plan and available internal and external programs/services.

• Applies clinical judgment to the incorporation of strategies designed to reduce risk factors and address complex clinical indicators which impact care planning and resolution of member issues.

• Using advanced clinical skills, performs crisis intervention with members experiencing a behavioral health or medical crisis and refers them to the appropriate clinical providers for thorough assessment and treatment, as clinically indicated.

• Provides crisis follow up to members to help ensure they are receiving the appropriate treatment/services.

​Enhancement of Medical Appropriateness and Quality of Care

• Application and/or interpretation of applicable criteria and clinical guidelines, standardized case management plans, policies, procedures, and regulatory standards while assessing benefits and/or member’s needs to ensure appropriate administration of benefit

• Using holistic approach consults with supervisors, Medical Directors and/or other programs to overcome barriers to meeting goals and objectives; presents cases at case conferences to obtain multidisciplinary view in order to achieve optimal outcomes

• Identifies and escalates quality of care issues through established channels -Ability to speak to medical and behavioral health professionals to influence appropriate member care.

• Utilizes influencing/motivational interviewing skills to ensure maximum member engagement and promotes lifestyle/ behavior changes to achieve optimum level of health

• Provides coaching, information and support to empower the member to make ongoing independent medical and/or healthy lifestyle choices.

• Helps member actively and knowledgably participate with their provider in healthcare decision-making.

• Analyzes all utilization, self-report and clinical data available to consolidate information and begin to identify comprehensive member needs.

Monitoring, Evaluation and Documentation of Care

• In collaboration with the member and their care team develops and monitors established plans of care to meet the member’s goals

• Utilizes case management and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures.

• Exhibits the following Clinical Case Manager

Required Qualifications

• Candidate must have active and unrestricted Illinois Registered Nurse (RN) License

• 3-5 years clinical practical experience

• Confidence working at home/independent thinker, using tools to collaborate and connect with teams virtually

• Excellent analytical and problem-solving skills

• Effective communications, organizational, and interpersonal skills.

• Ability to work independently

• Effective computer skills including navigating multiple systems and keyboarding

• Demonstrates proficiency with standard corporate software applications, including Microsoft Word, Excel, Outlook, and PowerPoint, as well as some special proprietary applications

Preferred Qualifications

• 2-3 years of care management, discharge planning and/or home health care coordination experience

Education

• Associate’s Degree in Nursing (REQUIRED)

• Bachelor’s Degree in Nursing (PREFERRED)

License

• Active and unrestricted Illinois Registered Nurse (RN) License