Current Career Opportunities

Responsibilities

• Perform the primary functions of case management–assessment, planning, facilitation, coordination, monitoring, evaluation, and advocacy–as appropriate in the health plan context to help members with high health complexity overcome biological, psychological, social and/or health system barriers to improvement and to achieve their desired clinical and functional outcomes.
• Conduct comprehensive assessments and develop personalized care plans in accordance with professional case management and accreditation standards, using evidence-based tools and applying relationship-building, motivational interviewing, risk-prioritization, and other related skills.
• Work collaboratively with members, families, and providers throughout the case management process, drawing upon knowledge of clinical, regulatory, and quality standards, health plan products and benefits, and community resources.
• Support members at all stages of their health care journey and across multiple settings and specialty areas, connecting with multiple providers and community-based organizations; guide members in accessing services to support their health and wellness goals in accordance with their benefits, partnering effectively with the Plan’s customer service, providers relations, and/or utilization management teams.
• Demonstrate a commitment to integrated, multi-disciplinary practice by proactively tapping into the expertise of the Plan’s clinical team of physicians, nurses, mental health clinicians, pharmacists, and colleagues in other departments who can help ensure the best possible experience and outcomes for the member.
• Participate in department and organization-wide initiatives to enhance member health and wellness, improve the quality of care, and generate cost-savings for our customers.

Qualifications

• Graduate of an approved program in professional nursing: RN, VT licensure and ability to apply for Compact License or active multi-state licensure required, BSN desired;
• OR Licensed Clinical Social Worker (LICSW) in the State of Vermont or comparable degree and licensure in an allied mental health profession.
• 5 years of varied clinical practice experience required, preferably in a health care setting. Experience in the following clinical areas strongly desired: inpatient and post-discharge care, management of chronic conditions, including medical and mental health conditions, and substance use disorders.
• 1-3 years of case management or similar experience desired.
• Active CCM certification preferred or initiated within 2 years of hire. Completion of CCM certification required within 3 years of hire.

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Responsibilities

• Conduct clinical reviews for preservice, concurrent, and retrospective authorizations that promote efficient and medically appropriate use of members benefits to provide cost effective and high-quality care. 
• Self-directed, working independently and collaboratively with the team to facilitate care using clinical skills, principles of managed care, nationally recognized medical necessity criteria, and company medical policies.
• Emphasis on utilization management, discharge planning, clinical outcomes and the ability to assess, analyze, draw conclusions, and construct effective solutions, identify questionable cases and refer to superior or medical director for review.
• Proficient with multiple IT systems.
• Strong written and spoken communication skills
• Able to follow regulatory requirements with audit feedback incorporated into future work.

Qualifications

• RN with Vermont License required, BSN desired. 
• 3-5 years of relevant experience in a variety of appropriate clinical health care settings (inpatient, outpatient, or differing levels of care).
• 1- 3 years of insurance related experience desired. 
• Must be willing to participate in on-going CEU training.
• Must be willing to participate in after hours on call rotation 

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Responsibilities:

• Provide consultation and analyses to client partners and support the Accountable Blue product initiatives and programs in the areas of Medical Cost and Utilization Management, Sales and Marketing, and Quality Improvement and Wellness.
• Track, measure, and convey results to internal and external audiences. Analysis and projects will focus on product, financial, quality improvement, and medical utilization data to provide insight and identify areas of opportunity.
• Act as a consultant to client partners and program stakeholders to improve the design and evaluation of health plan benefits and programs; complete analyses to guide decisions; make recommendations on program direction; support client initiatives and develop reports and analyses based on multiple sources of data and consult with internal and external parties.
• Additional responsibilities include developing and monitoring models to assess program impact and value; researching and developing benchmarks; analyzing trends; developing presentations and participating in external meetings to advance the Plan’s strategic objectives.

Qualifications: 

• Four-year college degree in health care, business, statistics, math or a closely related field required.
• Three to five years of population health and/or health insurance experience, including experience in reimbursement methodologies, data research and reporting required. 
• Microsoft Excel and SAS programming knowledge required.

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