POSITION SUMMARY
The Case Manager (Maternity) helps members navigate their healthcare needs by coordinating care plans and connecting them with appropriate clinical resources, specialized services, and vendor partners. As part of Allied’s Enhanced Case Management (ECM) team, this role reviews clinical documentation and claims information, identifies appropriate referrals, and collaborates with clinicians and other case managers to support each member’s care needs.
Serving as a key point of coordination among members, clients, brokers, vendors, and Allied’s internal teams, this position facilitates communication, resolves case-related issues, and supports the implementation of care plans. The Case Manager I also documents case activity, evaluates the impact of services on member health outcomes and costs, and identifies opportunities to improve care coordination and the member experience.
ESSENTIAL FUNCTIONS
- Review clinical documentation, claims, and baseline case information for health needs related to behavioral health, wellness, specialty prescription medications, maternity, and other areas.
- Develop strategic care plans to support members with varying health needs by connecting them with specialized vendor partners and Allied Care Clinicians who can address those needs.
- Implement care plans by coordinating with members, clients, Allied staff, and specialized vendor partners, as appropriate.
- Work closely with the Clinical Case Management team and other case managers to obtain the clinical information needed to support care plans. Present cases as needed to collaboratively identify and resolve escalated casework issues.
- Communicate with CMS to obtain essential member information.
- Facilitate and maintain relationships with prescription drug vendors, negotiate pricing as needed, manage member setup, and provide ongoing support.
- Document the impact of casework, including cost savings and improvements in member health outcomes resulting from the implementation of care plans.
- Perform weekly and monthly administrative tasks.
- Serve as a liaison among clients, brokers, members, Allied executives, and various Allied departments.
- Identify and troubleshoot process issues, and collaborate with the ECM team and other Allied departments to optimize internal processes.
- Perform other duties as assigned.
EDUCATION
- A bachelor’s degree or equivalent work experience is required.
EXPERIENCE AND SKILLS
- Two years of experience with group health insurance and self-funded health plans required.
- Excellent verbal and written communication skills.
- Excellent interpersonal and customer service skills.
- Excellent organizational skills and attention to detail.
- Excellent time management skills, with a proven ability to meet deadlines.
- Ability to review information, assess problems, and propose viable solutions.
- Strong analytical and problem-solving skills.
- Experience with Medicare, Medicaid, case management, and prescription drug benefits preferred.
- Experience in a clinical or social work position is a plus.
- Experience working in a hospital system is a plus.
- A life and health insurance producer’s license is preferred but not required.
- Proficiency with Microsoft Office Suite or related software.
POSITION COMPETENCIES
- Accountability
- Analytical Thinking
- Collaboration
- Communication
- Customer Focus
- Functional Expertise
- Initiative
PHYSICAL DEMANDS
- This is a standard desk role requiring extended periods of sitting and computer work.
- Ability to communicate by telephone.
WORK ENVIRONMENT
- Remote.
Bachelor's degree or equivalent work experience required; 2+ years group health insurance and self-funded health plans experience; strong communication, organizational, analytical, and time management skills; Microsoft Office proficiency.
Key Responsibilities
- reviewing clinical documentation
- developing care plans
- coordinating with vendors
Skills & Tools
Microsoft Office
Job Details
- Category: Healthcare Services - Allied Health
- Seniority: Mid Level
- Commitment: Full Time
- Workplace: Remote — United States
- Salary: USD 50,000 – 55,000 / year
- Languages: English
About Allied Benefit Systems
A healthcare benefits administrator providing case management and care coordination services. — Industry: Healthcare