Care Management Clinician

pacificsource; North Carolina; Hybrid; USD 70,000 - 100,000; Full time

Job summary

PacificSource is seeking an experienced Clinician Care Manager to support members’ wellness through advocacy, assessment, planning, and service facilitation. You will collaborate with providers, payers, and care teams to ensure high-quality, cost-effective outcomes.

This role requires an active RN/LPC/LMFT/LCSW license and CCM certification (or CCM within two years). Knowledge of health insurance benefits and strong communication are essential.

Qualifications

• Requires active RN, LPC, LMFT, or LCSW license.
• CCM certification must be obtained at hire or within two years.
• Knowledge of health insurance and state mandated benefits.
• Experience with case management practices including advocacy, assessment, planning, communication, and service facilitation.

Responsibilities

• Facilitate client wellness and autonomy through advocacy, assessment, planning, communication, education and service facilitation.
• Collect and assess client information to develop individualized care management plans.
• Coordinate with service providers to ensure safe, effective, client-centered, timely and cost-efficient care.
• Maintain client privacy and health records in compliance with HIPAA and regulatory standards.
• Interact with internal teams to support quality customer service and medical contract interpretation.

Skills

Communication skills

Healthcare knowledge

Advocacy

Education

RN license

LPC/LMSW/LMFT licensure

CCM certification

Job description

Looking for a way to make an impact and help people?

Join PacificSource and help our members access quality, affordable care!

PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, sex, sexual orientation, gender identity, national origin, genetic information or age. PacificSource values the diversity of our community, including those we hire and serve. We are committed to creating and fostering a work environment in which individual differences and diversity are appreciated, respected and responded to in ways that fully develop and utilize each person's talents and strengths.

Case management is a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet the client's health and human service needs. It is characterized by advocacy, communication, and resource management and promotes quality and cost-effective interventions and outcomes. Clinicians incorporate the essential functions of professional case management concepts to enhance patients' quality of life and maximize health plan benefits. These functions include but are not limited to: coordination and delivery of healthcare services, consideration of physical, psychological, and cultural factors, assessment of the patient's specific health plan benefits, and additional medical, community, or financial resources available.

Essential Responsibilities:

• Clinician Care Managers facilitate the achievement of client wellness and autonomy through advocacy, assessment, planning, communication, education, resource management, and service facilitation.
• Collect and assess patient information pertinent to patient's history, condition, and functional abilities in order to develop a comprehensive, individualized care management plan that promotes appropriate utilization, and cost-effective care and services.
• Based on the needs and values of the client, and in collaboration with all service providers, the clinician links clients with appropriate providers and resources throughout the continuum of health and human services and care settings, while ensuring that the care provided is safe, effective, client-centered, timely, efficient, and equitable.
• Clinicians have direct communication among, the client, the payer, the primary care provider, and other service delivery professionals. The case manager is able to enhance these services by maintaining the client's privacy, confidentiality, health, and safety through advocacy and adherence to ethical, legal, accreditation, certification, and regulatory standards or guidelines.
• Interact with other PacificSource personnel to assure quality customer service is provided. Act as an internal resource by answering questions requiring medical or contract interpretation that are referred from other departments, as well as physicians and providers of medical services and supplies. Assist employers and agents with questions regarding healthcare resources and procedures for their employees and clients.
• Practice and model effective communication skills: both written and verbal.
• Utilize and promote use of evidence-based tools.
• Utilize lean methodologies for continuous improvement.

Supporting Responsibilities:

• Meet department and company performance and attendance expectations.
• Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
• Perform other duties as assigned.

SUCCESS PROFILE

• Work Experience: Minimum of three (3) years of clinical experience, including case management. Insurance industry experience preferred.
• Education, Certificates, Licenses: Active, unrestricted Registered Nurse (RN) license, Licensed Professional Counselor (LPC), Licensed Marriage and Family Therapist (LMFT), or Licensed Clinical Social Worker (LCSW) credential required. Certified Case Manager Certification (CCM) as accredited by CCMC (The Commission for Case Management) also required at time of hire or within two years of hire date.
• Knowledge: Knowledge of health insurance and state mandated benefits. Experience and expertise in case management practice including advocacy, assessment, planning, communication, education, resource management and service facilitation. Ability to deal effectively with people who have various health issues and concerns. Knowledge and understanding of contractual benefits and options available outside contractual benefits. Knowledge of community services, providers, vendors and facilities available to assist members. Ability to use computerized systems for data recording and retrieval. Assures patient confidentiality, privacy, and health records security. Establishes and maintains relationships with community services and providers. Maintains current clinica