Care Management Clinician
Care Management Clinician
- Primary Job Purpose:
Provides clinical care management (such as case management, disease management, and/or care coordination) to best meet the member’s specific healthcare needs and to promote quality and cost-effective outcomes. Oversees a collaborative process with the member and those involved in the member’s care to assess, plan, implement, coordinate, monitor and evaluate care as needed.
At Cambia, our values are fundamental to achieving our Cause of transforming the health care industry. They guide our actions and bring diverse perspectives together to improve the health care journey better for those we serve. All eight values are equally important and linked to the others: Empathy, Hope, Courage, Trust, Commitment, Innovation, and Accountability. These values are not just words on paper - we live them every day.
Responsibilities & Requirements
- Knowledge of health insurance industry trends, technology and contractual arrangements.
- General computer skills (including use of Microsoft Office, Outlook, internet search). Familiarity with health care documentation systems.
- Strong oral, written and interpersonal communication and customer service skills.
- Ability to interpret policies and procedures, make decisions, and communicate complex topics effectively.
- Strong organization and time management skills with the ability to manage workload independently.
- Ability to think critically and make decision within individual role and responsibility.
Normally to be proficient in the competencies listed above:
Care Management Clinician would have a/an Associate or Bachelor’s Degree in Nursing or related field and 3 years of case management, utilization management, disease management, or behavioral health case management experience or equivalent combination of education and experience.
Required Licenses, Certifications, Registration, Etc.
Must have licensure or certification, in a state or territory of the United States, in a health or human services discipline that allows the professional to conduct an assessment independently as permitted within the scope of practice for the discipline (e.g. medical vs. behavioral health) and at least 3 years (or full time equivalent) of direct clinical care.
Must have at least one of the following:
- Certification as a case manager from the URAC-approved list of certifications; or
- Bachelor’s degree (or higher) in a health or human services-related field (psychiatric RN or Master’s degree in Behavioral Health preferred for behavioral health care management); or
- Registered nurse (RN) license (must have a current unrestricted RN license for medical care management)
General Functions and Outcomes
- Responsible for essential activities of case management including assessment, planning, implementation, coordination, monitoring and evaluation.
- Assessment: collection of in-depth information about a member’s situation and functioning to identify individual needs.
- Planning: identification of specific objectives, goals, and actions designed to meet the member’s needs as identified in the assessment.
- Implementation: execution of the specific case management activities that will lead to accomplishing the goals set forth in the plan.
- Coordination: organization, securing, integrating and modifying resources.
- Monitoring: gathering sufficient information to determine the plan’s effectiveness and the evaluation phase should determine the effectiveness of reaching the desired outcomes. Applies clinical expertise and judgment to ensure compliance with medical policy, medical necessity guidelines, and accepted standards of care. Utilizes evidence-based criteria that incorporates current and validated clinical research findings. Practices within the scope of their license.
- Consults with physician advisors to ensure clinically appropriate determinations.
- Serves as a resource to internal and external customers.
- Collaborates with other departments to resolve claims, quality of care, member or provider issues.
- Identifies problems or needed changes, recommends resolution, and participates in quality improvement efforts.
- Responds in writing or by phone to members, providers and regulatory organizations in a professional manner while protecting confidentiality of sensitive documents and issues.
- Provides consistent and accurate documentation.
- Plans, organizes and prioritizes assignments to comply with performance standards, corporate goals, and established timelines.
At Cambia, we advocate for transforming the health care system. You aren’t satisfied with the status quo and neither are we. We're looking for individuals who are as passionate as we are about transforming the way people experience health care. We offer a competitive salary and a generous benefits package. We are an equal opportunity employer dedicated to workforce diversity and a drug and tobacco-free workplace. All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, age, sex, sexual orientation, gender identity, disability, protected veteran status or any other status protected by law. A drug screen and background check is required.
Cambia’s portfolio of companies spans health care information technology and software development; retail health care; health insurance plans that carry the Blue Cross and Blue Shield brands; pharmacy benefit management; life, disability, dental, vision and other lines of protection; alternative solutions to health care access; and free-standing health and wellness solutions.
We have nearly a century of experience in developing and providing health solutions to serve our members. We had our beginnings in the logging communities of the Pacific Northwest as innovators in helping workers afford health care. That pioneering spirit has kept us at the forefront as we build new avenues to improve access to and quality of health care for the future.
Need help finding the right job?
Cambia Health Solutions, headquartered in Portland, Oregon, is dedicated to transforming health care. We put people at the heart of everything we do as we work to make the health care system better and more economically sustainable for people and their families. Our company reaches more than 70 [...]