It’s an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.

The Clinical Care Manager will perform as a Lead Care Manager responsible for the overall local integrated, holistic person-centered care management interventions for a member’s physical health, behavioral health (BH) and psychosocial support needs. The Clinical Care Manager will perform a variety of diverse and complex face-to- face and telephonic care management responsibilities. The Clinical Care Manager will organize, coordinate, and provide care coordination and care management services to at-risk and complex individuals through a member-centric, team-based approach. The Clinical Care Manager facilitates and acts as the clinical link with the member’s Primary Care Team (PCT) which includes the Member, Caregiver(s), Primary Care Provider, community agency providers, pharmacists, social workers, and others involved with the Member’s care. The Care Manager will ensure the right care is provided in the right setting and at the right time by applying designated Level of Care criteria.

Our Investment in You:

• Full-time remote work
• Competitive salaries
• Excellent benefits

Key Functions/Responsibilities:

• Manages a panel of high risk, medically, behaviorally and socially complex members
• Administer Comprehensive Assessment, medication reconciliation, convene local care teams, develop, document, and implement integrated care plans Completes timely initial and on-going face-to-face comprehensive assessments with Member to evaluate member’s medical, behavioral health, functional status, and socioeconomic needs
• Collaborates with Members of the local care team, including community/state agencies and internal staff
• Facilitates meetings of the Interdisciplinary Care Team (ICT) and serves as clinical subject matter expert and advocate for members
• Develops and communicates an Individual Plan of Care (IPC) with member, caregiver(s), providers and other ICT members to address identified needs and ensures its implementation
• Evaluates the effectiveness of the IPC and progress against goals Utilizes evidence-based guidelines to assist member in understanding their disease process and increase their capacity for self-management and optimal health
• Utilizes data to ensure that clinical interventions result in improved clinical outcomes and appropriate utilization of services at the right time, right place, and right setting
• Evaluates the effectiveness of alternative care services and ensures that cost effective, quality care is maintained according to standards
• Provides pro-active management and follow up (via home visits, telephone, etc.) of the Member’s individualized plan of care (IPC)
• Facilitates member and caregiver access to community resources relevant to the member’s needs
• Documents clinical assessments and coordination of care in the medical management information system in a timely manner that meets regulatory and accreditation standards
• Collaborates with discharge planning staff at contracted hospitals, proactively anticipating member needs and preferences
• When designated as Lead Care Manager will lead discharge planning meetings, either in-person or telephonically
• Provides culturally competent care coordination in keeping with the Member’s racial, ethnic, linguistic and sexual orientation
• Facilitates sharing of essential clinical or psychosocial information related to the member’s care
• Be knowledgeable of the contractual requirements of the Care Management agreement with DHHS and contracted vendors and community agencies
• Adhere to Company and Department Policies and Procedures as well as State Contractual Requirements
• Maintain HIPAA standards and confidentiality of protected health information
• Reports critical incidents and information regarding quality of care issues
• Serves and participates in pertinent committees and meetings as needed
• Other duties as assigned

Qualifications:

• Active, unrestricted, Registered Nurse license required (NH or MA depending on service area)
• Bachelor’s degree in nursing or Associate’s degree in Nursing and relevant work experience
• 3 years clinical experience working with people who have multiple, chronic or complex health conditions in an acute care or health insurance environment
• 2 years of experience in care management, care coordination and/or discharge planning
• Commission for Care Manager (CCM) certification preferred
• Prior work with Medicaid population preferred
• Bilingual preferred
• Work is will be performed in the field as well as some home/corporate office work

About WellSense

WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances.

Required Skills

Required Experience