Sandvik Rock Processing Solutions is hiring a CARE MANAGER to play a pivotal role on the Stanford Health Plan Clinical Operations team. You will be responsible for risk stratification, concurrent review, and managing complex cases for high-risk members, coordinating care and facilitating safe transitions through direct patient engagement.
What You'll Do
- Support proactive hospital discharge planning, transfers, and redirections through collaborative care planning.
- Develop and update individualized care plans for complex case management patients.
- Proactively interface with HMOs, physicians, internal staff, and family members to assist in developing comprehensive care plans.
- Complete health risk assessments for selected senior patients as needed.
- Serve as a liaison between hospital, health plan, providers, caregivers, family, and the patient.
- Identify opportunities to improve utilization, quality of care, access issues, and physician profiling.
- Act as a resource for provider and patient education as necessary.
- Reduce avoidable inpatient and SNF bed days through concurrent review and collaboration.
- Apply standard clinical criteria, document decisions, and issue related member and provider correspondence.
- Ensure seamless and safe transition of care through bedside visits and post-discharge coordination.
- Proactively review Health Risk Assessments and at-risk populations to identify patients for case management.
- Provide feedback on the appropriateness of complex case management referrals.
- Develop and implement care coordination services for complex patients, including scheduling appointments and linking with community resources.
- Identify and refer high-risk members to chronic disease care programs.
- Maintain a daily electronic case management list using designated software.
- Attend weekly interdisciplinary care team meetings to discuss complex cases.
- Manage a caseload of approximately 50-150 complex and/or rising risk case management patients.
- Provide telephonic and onsite case management, which may include periodic visits at the member’s home or provider settings.
- Complete comprehensive assessments of clinical and non-clinical risk factors impacting a member’s health status.
- Develop and coordinate implementation of individualized, member-centered care plans.
- Coordinate and communicate effectively with Medical Directors and clinical staff.
- Meet departmental review and documentation standards for all work assignments.
- Adhere to the policy and procedure of assigned hospital(s).
- Build and maintain appropriate relationships on behalf of SHC Health Plan.
- Attend departmental and company meetings as indicated by management.
- Adhere to safety, P4P’s, HIPAA and compliance policies.
What We're Looking For
- High School Diploma or GED equivalent.
- BSN degree from an accredited university.
- Minimum of 2 years case management in a managed care environment (HMO, Health Plan, IPA or Medical Group).
- Minimum of 1 year complex case management experience.
- Experience in concurrent review, discharge planning and transition management.
- Working knowledge of CMS and NCQA requirements for documentation and communication.
- Verbal and written communication skills that demonstrate courtesy, compassion and helpfulness.
- Advanced Windows skills including keyboarding, mouse movement and computer data entry.
- Strong organizational and multi-tasking skills.
- Ability to work with others in a flexible, cooperative and collaborative manner.
- Working knowledge of clinical criteria sets (Milliman, Interqual, Medicare, Health Plan).
- Knowledge of medical terminology and medical coding, including ICD-10, CPT, HCPCS, ASA.
- Knowledge of medical management statistics relating to UM/CM and prior authorization process management.
- Extensive knowledge of risk stratification methods and complex case management criteria.
- Working knowledge of regulatory entities and regulations (CMS, DMHC, NCQA, etc.).
- Working knowledge of care management systems.
- Strong time management and ability to organize and manage multiple priorities.
- Excellent oral and written communication skills.
- Strong customer orientation.
- Ability to work within a team environment as well as an individual contributor.
- Ability to solve practical problems and deal with a variety of concrete variables.
- Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.
- Maintain attention to detail when completing multiple or repetitive tasks.
- Ability to create basic business correspondence and write descriptive and factual prose.
- Ability to develop and maintain strong rapport with clients.
- Understands client needs, identifies root causes of problems, and develops creative and pragmatic solutions.
- Uses logic and various problem-solving techniques to deal with technical queries.
- Demonstrated ability to review utilization reports and data.
- Ability to identify trends and make recommendations for improvement.
- Registered Nurse - State Licensure And/Or Compact State Licensure.
Nice to Have
- 2-3 years in a senior role.
- CCM - Certified Case Manager.
Team & Environment
This role is a key member of the Stanford Health Plan Clinical Operations team.
Benefits & Compensation
- Compensation is generally starting at $72.55 - $96.15 per hour.
Work Mode
This is an onsite position at Stanford Health Care.
Sandvik Rock Processing Solutions is committed to providing an exceptional patient & family experience and strongly values diversity, equal opportunity, and non-discrimination.
SHC does not discriminate against any person on the basis of race, color, sex, sexual orientation or gender identity and/or expression, religion, age, national or ethnic origin, political beliefs, marital status, medical condition, genetic information, veteran status, or disability.
