Quality Outreach Case Manager III

Medica's Quality Outreach Case Manager works to establish trusting member relationships through active listening, clinical guidance and timely follow-through to improve health and quality outcomes. The Quality Outreach Case Manager routinely connects with members through phone and text outreach on post-discharge and ER follow-up needs, medication adherence needs, and ongoing chronic condition care management. Using member-centered discussion, the Quality Outreach Case Manager assesses member health status, coordinates additional resources and motivates them to adhere to their care plan. The Quality Outreach Case Manager also ensures streamlined support for our providers by blending their nursing expertise and genuine care, helping to get high-need members back on track. This is a highly collaborative role that is positioned to support Medica's Case Management and Quality teams. This role will be aligned under Case Management and will work closely alongside the Complex Case Management team to support quality initiatives.

A successful Quality Outreach Case Manager is driven by connection-energized by helping members, collaborating with care teams, and supporting providers. Whether it's scheduling an eye exam, coordinating care, or ensuring medications are filled, they excel at making a difference through meaningful relationships and proactive outreach. The Quality Outreach Case Manager seeks to help drive Quality performance and improve member outcomes. The Quality Outreach Case Manager is skilled at telephonic work, including navigation of the health plan and community providers and facilities. This includes having exceptional skills in organization, prioritization, problem solving, and autonomy. Interpersonal and external provider/care system relationship skills are essential. Maintaining a strong working knowledge of numerous Medica sponsored and external health programs and services is also required. Performs other duties as assigned.

Key Accountabilities

• Conducting regularly scheduled member outreach calls to address utilization gaps including post-discharge follow up, frequent ER use and medication adherence issues.
• Coordinate and manage care for members with chronic conditions, including COPD and CHF.
• Evaluating and documenting member health status, risk levels, complication progression and reasons for non-adherence with care plans.
• Providing education, reinforcement and motivational coaching to reengage member commitment to clinical direction.
• Helping members secure medications, transportation, specialist referrals, payment support or other potential socioeconomic barriers to care.
• Serving as point-of-contact for assigned members, building trusted relationships that promote accountability to reach care benchmarks.
• Provide guidance, input and support to Quality and Clinical leadership as they develop and improve programs and outreach

Minimum Qualifications

• Associate or bachelor's degree in nursing
• 5+ years of clinical/acute care nursing experience with focus in chronic condition management, post-acute, utilization management, or case management preferred

Required Certifications/ Licensure

• Current, unrestricted RN license in the state of residence
• Certified Case Manager (CCM) preferred, or ability and commitment to obtain within two years of hire

Preferred Qualifications

• Experience working with vulnerable and complex populations, including multiple age groups, ethnic and socioeconomic backgrounds provided in a clinical, home care or telephonic environment; direct case management experience strongly preferred
• Knowledge of managed care principles and regulatory guidelines preferred
• Proficiency in electronic health records and care management software
• Coding classes and a CPS, CRC, and/or medical claims billing experience strongly preferred.
• Familiarity and understanding of healthcare quality improvement standards and principles including HEDIS, Gaps in Care, STARs, and the impact from a health plan perspective

Skills and Abilities:

• Experience collaborating with providers and other health professionals
• Demonstrated autonomy, initiative in handling work, strong analytical and problem-solving skills to proactively assess project needs and barriers and initiate solutions
• Strong command of motivational interviewing, member assessment and care planning
• Highly organized and emotionally intelligent
• Comfortable multitasking with excellent time management skills
• Self-starter, independent functioning with strong organizational and communication skills
• Ability to effectively facilitate phone conversations to engage members in prevention and medical management initiatives by scheduling and conducting outreach to selected populations, tracking of outreach efforts and providing reports on outcomes
• Excellent communication and interpersonal skills with the ability to effectively engage and collaborate with diverse stakeholders
• At ease working with various populations: multiple age groups, vulnerable and complex populations, and diverse ethnic and socioeconomic backgrounds, including seniors and those with disabilities
• Advanced computer skills and application knowledge specifically Microsoft Office applications, with ability to master multiple computer programs and documentation platforms
• Attention to detail and accuracy a must
• High level of precision tracking detailed information and identifying potential errors.
• Ability to seamlessly adjust projects based on department priorities and to manage multiple projects at one time.
• Assist and participate in meeting company and department goals inclusive of quality improvement activities

This position is a Remote role. To be eligible for consideration, candidates must have a primary home address located within any state where Medica is registered as an employer - AR, AZ, FL, GA, IA, IL, KS, KY, MD, ME, MI, MN, MO, ND, NE, OK, SD, TN, TX, VA, WI

The full salary range for this position is $70,700 - $121,200. Annual salary range placement will depend on a variety of factors including, but not limited to, education, work experience, applicable certifications and/or licensure, the position's scope and responsibility, internal pay equity and external market salary data. In addition to compensation, Medica offers a generous total rewards package that includes competitive medical, dental, vision, PTO, Holidays, paid volunteer time off, 401K contributions, caregiver services and many other benefits to support our employees.

The compensation and benefits information is provided as of the date of this posting. Medica's compensation and benefits are subject to change at any time, with or without notice, subject to applicable law.

We are an Equal Opportunity employer, where all qualified candidates receive consideration for employment indiscriminate of race, religion, ethnicity, national origin, citizenship, gender, gender identity, sexual orientation, age, veteran status, disability, genetic information, or any other protected characteristic.