Care Manager

The Care Manager will work to enhance the health plan's world class member experience by maximizing care management initiatives to optimize health outcomes and affordability. The incumbent will assist members in navigating the health care system as a collaborative partner to promote wellness, problem-solve, and help them to realize their personal healthcare goals. The Care Manager will help members to identify and anticipate gaps in care and resources by providing education and strategies to empower members to better manage their current health status. The role includes member and provider outreach, data collection, analysis and reporting, clinical review, medical and behavioral health assessments, and documentation in compliance with NCQA, OCI and all other state and federal regulations.

About us

Common Ground Healthcare Cooperative is a "who" not a "what." As a cooperative, we are thousands of Wisconsin residents buying health insurance together, supported by a staff focused on providing the best possible service to our members. We are a not-for-profit cooperative, governed by a Board of Directors made up of members who purchase our health insurance. Any earnings are returned to our members in the form of lower prices and better services.

Our Culture

We are here because we can make a difference in the lives of others. We believe that serving our community is meaningful work and we hold it in the highest regard. We are vibrant, dynamic, and value-focused individuals who welcome different points of view, perspectives, and thoughtful solutions to challenges. We encourage teamwork, integrity, mutual respect, honesty and doing the right thing. We know the importance of showing appreciation for a job well done, celebrate our achievements, and make room for fun and laughter in the workplace.

Our Job

We are continuously improving our efforts to serve our members and lower their overall healthcare cost through our three key pillars: Advocacy - Partnership - Innovation.

Does this sound like a culture you'd like to be a part of?

Come join a fun team of committed professionals!

Utilize Your Skills By:

• Engage with members and provider case coordinators to ensure individual member needs are met
• Telephonically manage cases on a long- or short-term basis per needs of the members, following guidelines, policies, and procedures, as well as other standardized criteria in the healthcare industry
• Initiate and maintain contact with the member/family, provider, and multidisciplinary team as needed throughout the continuum of care and complete a telephonic assessment, including physical, psychosocial, emotional, spiritual, environmental, and financial needs
• Evaluate members, provide intervention, and monitor effectiveness of treatment plans, refer to programs appropriately, and report measurable outcomes that record effectiveness of interventions
• Identify gaps in care and anticipate future needs of the members, provide education and community resources to fill those gaps and future needs, meeting members where they are at and empowering self-care management skills to obtain optimal health outcomes
• Use claims processing tools to review and research paid claim data to develop a clinical picture of a member's health and identify for participation in appropriate programs.

Skill Requirements

• Ability to work independently and multitask, in a fast-paced environment, handling multiple assignments while prioritizing workload
• Ability to work and problem solve independently, while being an integral part of the team
• Highly developed critical thinking, problem-solving, time management and organizational skills
• Experience evaluating and modifying programmatic approaches to population health problems
• Strong interpersonal (written and verbal) and communication skills, ability to motivate others, customer service mindset, and effectiveness to work cross-functionally with others and autonomously
• Demonstrated ability to be adaptable to changing work environments and responsibilities
• Ability to meet productivity, quality, and turnaround time requirements on a daily, weekly and monthly basis
• Must be able to thrive in team environment and be willing to contribute at all levels with flexibility and a positive attitude.

What You'll Need to Bring:

Knowledge Requirements

• Unrestricted State of Wisconsin RN license
• 4 years clinical experience in healthcare
• 2 years of case management
• Computer proficiency and working knowledge of Microsoft Office Suite (Outlook, Word, Excel, Power Point)
• Familiarity of National Committee on Quality Assurance (NCQA) accreditation process and standards, preferred
• Experience with EPIC electronic medical record system, preferred
• Knowledge of medical claims and ICD-10, CPT and HCPCS coding preferred
• Knowledge of utilization management, case management, quality management, and quality improvement preferred
• Payer experience a plus

We've Got You Covered

CGHC offers competitive pay and broad range of programs to meet the needs of our employees to help protect your health, wealth, and future.