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The Case Manager works within a team environment to: (1) Develop, guide and provide case management services, utilize clinical expertise, and coordinate with the third party administrator and the medical management team. (2) Analyze medical trends, and intervene with members at high risk and/or high utilizers. (3) Interact with Nurse Navigator and Nurse Practitioner to provide seamless case management activities across the care continuum, (4) Interact with physicians, community/system resources, administrators, (5) Set collaborative case goals, determine the implementation plan and measure outcomes, and (6) Use data from an intelligent data system to identify appropriate health plan members, design interventions, implement the care plan in coordination with the health team and member, and document clinical and financial outcomes.

Education, Work Experience and Licensure:

• Bachelor’s Degree in Nursing

• Computer skills and ability to learn clinical information/data warehouse reporting systems

• Working knowledge of employee benefit plan design and operations

• Presentation, negotiation, problem solving and conflict resolution skills

• Excellent written and verbal communication skills

• Three to five years of progressively responsible experience is preferred, especially in case management

• Prior healthcare leadership is desirable and a strong record of nursing experience

• Evidence of working independently and effectively with other professionals and patients to achieve optimal member health

• Active Case Management Certification (CCM) or willingness to become certified as a case manager within 2 years