Medical Case Manager - Delaware

📋 Description

• • Serve as a Medical Case Manager responsible for ensuring members with complex medical and psychosocial needs have access to high-quality, cost-effective healthcare services within Delaware.
• • Conduct telephonic interviews and communicate effectively with members, healthcare providers, and external contacts to assess needs and coordinate care.
• • Perform holistic assessments of members’ medical, behavioral, and social needs to develop individualized plans of care aligned with clinical judgment and regulatory guidelines.
• • Collaborate with Primary Care Physicians, Medical Specialists, Home Health providers, and other ancillary healthcare professionals to coordinate member care across the continuum.
• • Collect and analyze member medical information from multiple sources including provider records and internal systems to identify unmet needs and guide intervention planning.
• • Educate members on illness/disease impact, pharmacy regimens, and care plan adherence to improve health outcomes and promote self-management.
• • Maintain current knowledge of medical terminology, diagnostic categories, disease states, and benefit designs to inform care planning and cost-effective decision-making.
• • Identify and leverage available community resources and agencies to support members’ needs beyond what the MCO covers.
• • Coordinate with other payers when applicable to align care management strategies and ensure seamless benefit coordination.
• • Monitor members’ progress toward care goals, reassessing and adjusting care plans as needed based on evolving clinical and social conditions.
• • Participate in interdisciplinary and interagency team meetings to facilitate comprehensive care coordination and resource alignment.
• • Work independently to identify, define, and resolve complex member issues while maintaining compliance with regulatory standards and company policies.
• • Attend required staff meetings, internal rounds, in-services, and continuing education forums to enhance clinical competency and maintain professional licensure.
• • Foster constructive relationships with peers, management, physician advisors, and interdepartmental teams through conflict resolution and feedback.
• • Educate internal health team colleagues on the role of case management and the unique needs of the populations served to promote collaborative solutions.
• • Participate in departmental and organizational quality improvement initiatives to advance care delivery standards.
• • Adhere strictly to HIPAA, data security policies, and the Company’s Code of Business Conduct when handling protected health information and member data.
• • Maintain accurate documentation of all member interactions, interventions, and care plan activities in compliance with regulatory and organizational requirements.
• • Travel within the assigned territory in Delaware is required as part of this full-time role to support member engagement and care coordination.
• • Operate within a team environment while maintaining autonomy in case management decision-making and daily responsibilities.