Care Manager I, Specialty Programs

Jobtailor; Connecticut; On-site; USD 75,000 - 95,000; Full time

Job summary

Jobtailor is seeking a skilled care coordinator to manage complex cases and optimize transitions across the continuum of care. You will apply established guidelines to ensure appropriate care levels and coordinate with members, families, and healthcare teams.

The role emphasizes utilization management, documentation, and collaboration with physicians. A strong background in case management and strong communication skills are essential for success in this position.

Qualifications

• Requires RN license or Bachelor degree in social work, health or behavioral science.
• Graduate degree preferred in Social Work or Health and Behavioral Science.
• Minimum of three years of experience serving members with special needs.

Responsibilities

• Perform care coordination using established guidelines to ensure appropriate level of care and transitions.
• Implement interventions for efficient utilization of benefits.
• Assess members' clinical needs against standards.
• Partner with members, families, physicians, and healthcare teams to coordinate resource utilization.
• Set priorities and plan interventions supporting self-care and independence.
• Monitor care activities for appropriateness and effectiveness.
• Consult internal stakeholders on complex cases and elevate to internal physician resources as needed.
• Document accurately according to practice standards and policies.

Skills

Care coordination

Clinical needs assessment

Utilization monitoring

Quality improvement

Variance analysis

Education

Bachelor's degree in social work, health or behavioral science

Graduate degree in Social Work or Health and Behavioral Science

Tools

Microsoft Office

Excel

Access

Word

Job description

• Perform care coordination duties using established guidelines to ensure appropriate level of care and plan transitions to the continuum of care for specialty populations.
• Implement interventions to ensure efficient utilization of benefits.
• Assess members’ clinical needs against established guidelines and/or standards.
• Implement high quality, cost-effective care based on a customized population model supported by clinical practice guidelines.
• Partner with members/families, physicians, and healthcare teams to meet member needs and coordinate resource utilization.
• Set priorities, plan, organize, and implement goal-directed interventions supporting self-care outcomes and transition to independent status.
• Ensure care for mandated non-compliant members through utilization monitoring.
• Document accurately and comprehensively according to practice standards and organizational policies.
• Evaluate care through problem solving, variance analysis, and quality improvement participation.
• Monitor member care activities and outcomes for appropriateness and effectiveness.
• Consult internal stakeholders on complex cases and elevate to internal physician resources as appropriate.
• Complete other assigned functions as requested by management.

Requirements

• Requires a license as an RN, or Bachelor degree in social work, health or behavioral science.
• Graduate level degree in Social Work or Health and Behavioral Science preferred.
• Requires a minimum of three (3) years’ experience serving members with special needs.
• Requires strong knowledge of the standards of practice for case managers.
• Requires strong knowledge of managed care principles.
• Requires strong knowledge of specialty population, as applicable.
• Requires strong organizational skills.
• Requires strong oral and written communication skills.
• Requires good PC skills and the ability to utilize Microsoft Office applications (Excel, Access, Word, etc.)
• Requires good problem solving and conflict resolution skills.
• Requires a car with valid New Jersey State License and Insurance for certain positions.
• Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware.

Core Competencies

Demonstrates expertise in care coordination, implementing high-quality, cost-effective care for specialty populations while ensuring compliance with established guidelines. Proficient in assessing clinical needs, utilizing managed care principles, and collaborating with healthcare teams to achieve optimal member outcomes.

Highest-signal resume keywords

• Licensed RN
• Bachelor's Degree in Social Work
• Three Years' Experience with Special Needs Members
• Knowledge of Managed Care Principles
• Strong Organizational Skills

Hard Skills

• Care Coordination
• Clinical Needs Assessment
• Utilization Monitoring
• Quality Improvement Participation
• Variance Analysis

Soft Skills

• Oral Communication
• Written Communication
• Problem Solving
• Conflict Resolution

Certifications & Qualifications

• RN License

Industry Keywords

• Case Management Standards
• Specialty Population
• Continuum of Care
• Self-Care Outcomes

Tools & Technologies

• Microsoft Office
• Excel
• Access
• Word