Non-Clinical Case Manager

Description

SUMMARY: The Non-Clinical Case Manager coordinates services and resources to help members of the organization’s Medicare Advantage Chronic Condition Special Needs Plan (C-SNP) achieve optimal health, wellness, and independence. Operating within the plan’s CMS- and NCQA-approved Model of Care (MOC), this role assesses members’ social, financial, and environmental needs; develops individualized care plans; facilitates referrals to community resources; and collaborates with healthcare providers, the Interdisciplinary Care Team (ICT), and community organizations to support member well-being. This position does not provide clinical counseling, psychotherapy, or other clinical behavioral health services, and escalates all clinical concerns to licensed clinical staff.

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following:

1. Assessment and Care Planning
2. Conduct comprehensive psychosocial and needs assessments of members’ social, financial, and environmental needs.
3. Administer initial Health Risk Assessments (HRAs) within CMS-required timeframes (within 90 days of enrollment) and annual reassessments for assigned C-SNP members, in accordance with the plan’s Model of Care (MOC).
4. Develop, implement, and update individualized, goal-oriented care plans (ICPs) based on HRA results, member needs, and member preferences, in collaboration with the member, caregiver(s), and the Interdisciplinary Care Team (ICT).
5. Screen members for social determinants of health (SDOH) and health-related social needs, including housing instability, food insecurity, transportation barriers, and social isolation.
6. Monitor member progress and update care plans as appropriate, including upon reassessment, change in health status, or care transition.
7. Identify members at risk for poor health outcomes and connect them with appropriate support resources.
8. Care Coordination and Advocacy
9. Coordinate access to community resources, including housing, transportation, food assistance, financial aid, caregiver support, and other social services, providing warm handoffs and following up to confirm members successfully connected with services.
10. Educate members regarding available health plan benefits, supplemental benefits (e.g., transportation, meal support, over-the-counter allowances), community programs, and support services.
11. Assist members in navigating and applying for state and federal assistance programs (e.g., Medicaid, Low-Income Subsidy/Extra Help, SNAP) when the member may qualify.
12. Connect members with chronic condition self-management education, medication adherence support programs, and nutrition resources appropriate to the C-SNP population.
13. Advocate for members by identifying and addressing barriers to care and services.
14. Assist with care transitions, including hospital discharges, post-discharge follow-up, and coordination of community services, including sharing the individualized care plan with the member, PCP, and receiving providers or facilities as appropriate.
15. Member Outreach and Engagement
16. Conduct telephonic and written outreach to engage members in the case management program, including newly enrolled members and members due for assessment or reassessment.
17. Perform diligent outreach efforts to locate and engage difficult-to-reach members, documenting all attempts in accordance with plan policy and CMS requirements.
18. Assist members with scheduling primary care, specialist, and behavioral health appointments and address barriers to appointment attendance in support of quality initiatives (e.g., HEDIS/Stars measures and preventive care gap closure).
19. Collaboration, Compliance, and Documentation
20. Collaborate with physicians, nurses, behavioral health providers, care managers, pharmacists, and community agencies to ensure coordinated care.
21. Participate in Interdisciplinary Care Team (ICT) meetings and case conferences, including assisting with scheduling, preparation, and documentation of ICT activities and outcomes.
22. Identify and promptly escalate clinical concerns, urgent needs, behavioral health crises, or changes in condition to licensed clinical staff (e.g., RN case managers) in accordance with plan protocols; this role does not perform clinical assessment or clinical judgment.
23. Maintain accurate and timely documentation in the case management system in accordance with organizational policies, CMS and NCQA Model of Care requirements, and audit-readiness standards.
24. Complete initial and annual SNP Model of Care (MOC) training and other required regulatory and compliance training.
25. Support MOC performance monitoring by meeting timeliness and completion goals for HRAs, care plans, and ICT activities.

Requirements

QUALIFICATION REQUIREMENTS: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily, including regular and consistent attendance. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

EDUCATION and/or EXPERIENCE:

• Bachelor’s or Master’s degree in Social Work (BSW or MSW), Human Services, Psychology, Public Health, or a related field.
• Social work licensure preferred (ACSW accepted; LCSW preferred).
• Relevant experience in case management, care coordination, managed care, healthcare, social services, or community-based programs may be considered in lieu of licensure.
• Strong communication, organizational, and problem-solving skills.
• Ability to manage multiple cases while maintaining confidentiality, professionalism, and compliance with applicable regulations.
• Successful completion of initial SNP Model of Care (MOC) training within required timeframe of hire and annually thereafter.
• Working knowledge of HIPAA regulations required.

PREFERRED QUALIFICATIONS:

• Experience in case management, care coordination, managed care, healthcare, or community-based services.
• Experience supporting a Medicare Advantage Special Needs Plan (C-SNP, D-SNP, or I-SNP), including Health Risk Assessments, individualized care plans, and Interdisciplinary Care Team processes.
• Knowledge of Medicare, Medicaid, community resources, and social determinants of health (SDOH).
• Experience working with diverse populations, older adults, and members with chronic conditions, and addressing complex social needs.
• Bilingual skills reflective of the member population served.