Lead Care Manager

The Lead Care Manager will support the pediatric and maternity care management population, with responsibilities that include managing complex cases, setting up cases, supporting audits, and assisting with the training and onboarding of new team members. This is a remote position; however, candidates must reside in North Carolina. Approximately 10% travel may be required for occasional meetings or team events in Raleigh or Charlotte. The standard work schedule is Monday through Friday, 8:00 AM to 5:00 PM.

Purpose: Oversees the care plans and care management activities of member needs primarily focused on behavioral health needs (including behavioral health, and social needs) to provide quality, cost-effective healthcare. Reviews and provides expert knowledge to inform personalized care plans for the most complex care members and provides guidance and/or support to the care management team. Oversees and reviews ongoing care plans/service plans, which may include which may include behavioral health and social determinant needs and works with care management team to identify providers, specialists, and community resources needed for care May perform telephonic, digital, home and/or other site visits outreach to assess member needs and collaborate with resources Provides insight and guidance on developing care plans and triaging issues to appropriate behavioral healthcare providers for complex care plans/service plans for members with high level acuity Provides guidance and expert knowledge as appropriate to healthcare management team members (including behavioral) to ensure quality control over work, ensure identified services are accessible to members, and adherence to contract policies and procedures Monitors the most complex care plans and/or member status and outcomes for changes in treatment side effects, complications and clinical symptoms and revises care plan/service based on member needs and issues identified including mental health and substance use disorders Provides subject matter expertise insights around mental health and social determinant needs for complex care plans based on prior experience to recommend enhanced member care within the care management plan Reviews member data to identify health risks and/or care gaps, and improve operating performance and quality care to address member’s needs/issues and provides recommendations in accordance with state and federal regulations Partners and collaborates with healthcare providers regarding complex cases as appropriate to facilitate member’s treatments to ensure member treatment requirements are met and determine a revised care plan/service plan for member if needed Collects, documents, and maintains member information and care management activities to ensure compliance with current state, federal, and third-party payer regulators Provides training and education to care management team and providers to ensure members are receiving high quality care and information regarding treatment plan options, procedures, referrals, and healthcare benefits including mental health and substance use disorders Partners with leadership team to improve and enhance care and quality delivery for members in a cost-effective manner Monitors management policies and procedures within the care management team to ensure compliance with corporate, state, and National Committee for Quality Assurance (NCQA) standards Works with senior management on escalated and complex care cases, and provides guidance to junior team members to address member concerns Works as a subject matter expert (SME) and provides training and education to care management team and providers to ensure members are receiving high quality care and information regarding service / care plan options, procedures, referrals, and healthcare benefits, which may include behavioral health and social determinant needs Monitors and review reports on a regular basis ensuring quality and productivity metrics are met and for