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Care Manager II

Peach State Health Plan Smyrna, Georgia

As a member of the Centene Medical Management/Health Services team, you’ll help innovate and execute strategies that redefine the industry standard for improving the lives and health of people. We’re a team of skilled physicians, nurses, pharmacists, social workers and health service experts who use our advanced clinical analytics to implement award winning programs, develop care, deliver partnerships, and work directly with our members to achieve outcomes that set us apart as industry leaders. Together, we’re transforming the health of communities, one person at a time.

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What does it take?

What are the qualities that will help you achieve success in this role at Centene?

Success Profile

  • Detail-oriented
  • Trustworthy
  • Personable
  • Quick-thinking
  • Multi-tasker
  • Good listener

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Our Medical Roles

Clinical & Nursing Opportunities at Centene

Our Clinical team is at the forefront of our purpose-driven work. Learn more about how you can help transform the health of our communities, one person at a time.

Overall Medical Management

A member of the Centene Medical Management team, we innovate and execute strategies that redefine the industry standard for improving the lives and health of people.

Concurrent Review Nurse

To ensure our members get the best quality of care, you’ll assess acute member health conditions, treatment and intervention options, and match them with providers, community and health plan resources.

Prior Authorization Nurse

You’ll ensure our members get the best quality services, assistive devices, and equipment to promote optimal health and independence in the community and help promote health and independence.

Care Manager

Working directly with members, interdisciplinary care team, providers and data analytics, you’ll identify member health risks and conditions and intervention and service options.

LTSS Program Specialist/Program Specialist Field Based

Working directly with our most vulnerable members, you’ll identify individual member health risks and opportunities to enhance independence, quality of life and community engagement.

Referral Specialist

You’ll use our data systems to directly assist providers, requesting services and treatments for our members.

Medical Director

To help support the individual needs of members and develop programs that address issues, you’ll review population health data, help design clinical programs, and develop care delivery partnerships.

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Job ID 1155617

Category Clinical & Nursing
Schedule Full-time

Position Purpose: Provides Case Management services to a specific clientele. Systematically identify and addresses fragmentation of care, and fill gaps in are using proactive initiatives. Assesses medical records for appropriateness, level of care provided and criteria determination. Identifies appropriate care for patients by evaluating high-risk cases, intensity and complexity of services, health care costs and non-compliance issues. Coordinates care between multiple providers. Develops care plans in coordination with providers, patients, families as appropriate and assess the effectiveness. Organizes and schedules training for all new Case Management employees. May conduct periodic quality assurance audits for accuracy and quality associated with training. May monitor and oversee workflow function in case management.

  • Coordination of Care
  • Contacts members of the medical team to discuss the patient’s course of progress and needs.
  • Arranges for all services required; coordinates services with the health care team to eliminate
  • duplication of service and conserve benefit dollars.
  • Contacts/visits family to check understanding of the patient’s diagnosis, prognosis and ability to provide caregiver support.
  • Checks home for safety factors and structural barriers, arranges for modifications
  • Reevaluates equipment, supplies, and services.
  • Identifies problems, anticipates complications and acts to avoid them; provides health instruction to the patient/family; refers the patient back to the physician or other health care team members as needed.
  • Identifies plateaus, improvements, regressions and depressions; counsels accordingly and recommends help.
  • Makes personal visits/contacts the physician to clarify diagnosis, prognosis, therapies, activities of daily living, etc.
  • Provides authorizations for any modalities of treatment recommended; investigates and suggests alternative treatments when appropriate.
  • Assists with getting information and forms for living wills, health care proxy, DNR order, etc.
  • Shares pertinent information about the patient with physician to achieve the best outcome.
  • Documents case summary based on information received and communicates with the beneficiary and involved providers.
  • Conducts personal visits to the patient’s home/hospital as needed.
  • Facilitates transfer of beneficiary throughout the different regions and within the region by collaborating with the military liaison to transition the beneficiary with minimal disruption of their health care services.
  • Coordinates the basic benefit and identifies and submits benefit modifications as appropriate or
  • submits a request to TMA for benefit exceptions/special programs.

  • Coordination of Financial Services
  • Assesses the benefit plan for coverage and limitations.
  • Negotiates for cost-effective rates for provider services, which includes:
  • Contacts multiple providers for a rate comparison of specialty items and identification of the most cost-effective approach.
  • Researches and identifies appropriate equipment that meets the beneficiary’s needs and pursues contracts with these providers.
  • Suggests medically appropriate alternatives to accomplish treatment plan goals more cost effectively.
  • Counsels the patient/ family on budgeting and notifying creditors.
  • Identifies financial distress and refers patient/family to appropriate community resources.
  • Helps patient /family sort and prioritize bills.
  • Acts as liaison among secondary insurance payers.
  • Aids with Behavioral/Motivational Activities
  • Explores patient’s feelings about his/her injury or illness; helps with associated trauma and frustration.
  • Monitors family’s feelings about the patient’s illness and observes the family’s ability to manage new emotional stress.
  • Offers information about patient’s condition.
  • Enlists qualified counselor to assist with problems arising from the injury or illness.
  • Post Discharge Follow-up
  • Contacts patient within 48 hours of discharge assuring proper support and services are in place to make a full recovery (i.e., equipment, home health, other services, transportation, etc.).
  • Ensures patient effectively navigates the health care system.
  • Evaluates Referrals and Pre-admission/Admission Counseling
  • Assesses patient’s condition, understanding of their injury and their ability to follow the treatment plan.
  • Contacts patients with upcoming medical or surgical admissions and discusses what they may expect before, during and after the admission.
  • Contacts members of the medical team to discuss the patient’s course of progress and needs utilizing available discharge information (if there was a hospitalization) and the initial needs assessment.
  • Works with physicians and hospitals to enforce treatment plans and orders, ensures patients receive specialty care and tests when ordered.

  • Qualifications:

    Education/Experience: Graduate of Nursing program, BSN Degree preferred. Five years clinical experience in a health care environment
    Two years proven case management experience required
    One year training or teaching experience preferred. Managed care experience desirable. Internal candidates must have functioned in the capacity of a Case/Care Manager I.

    License/Certification:Valid Registered Nurse, Clinical Psychologist, Marriage Family Therapist, Professional Counselor, Mental Health Counselor or Clinical Social Worker licensed to practice independently in the State where they reside. Ability to obtain additional State(s) licensure may be required. e, Valid State Drivers License, and Certified in Case Management (CCM) Strongly recommended. Must have and maintain current, valid and unrestricted clinical licenses.

    Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.

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    “Centene is an exciting company to work for, the pace at which we’re growing allows numerous advancement opportunities. Also, we foster an environment that supports and offers numerous leadership growth opportunities.”

    - Esmeralda Baig, SVP Operations, Complex Care Products

    “I assisted with one of the Provider fairs in the community. Seeing how much we care for our community and our patients was very eye opening.”

    - Julie Boulch, Director, Business Implementation Health Plan Initiatives

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    Our Awards

    Centene is consistently recognized for how well we treat our members, our people, and the communities we serve.

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    “Flexibility is key. Centene is a company of change.”

    Ashley Collier

    Started as a Referral Specialist, now a Project Manager IV

    See Ashley's career path

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