Job title Complex Care Manager- Center at AbsoluteCare
Overview This role is a member of the interdisciplinary care team (ICT), providing integrated case management for members with complex medical, behavioral, and social determinants of health needs. The CCM is assigned to an AbsoluteCare provider team. Members are assigned to the CCM based on health instabilities, utilization and healthcare spend. The CCM completes a comprehensive assessment and creates a person-centered care plan that identifies and prioritizes health care goals with the member. The CCM supports members in meeting their goals through clinical interventions, education, motivational interviewing, self-management coaching, and complex case management including navigation of health plan benefits. The CCM coordinates services with internal providers, health plan programs, community resources, and specialists to meet the member’s individual needs and achieve value-based outcomes. The CCM is located at the comprehensive care center and may conduct member visits telephonically, via telehealth, in the home, community, or other outpatient settings to support regular engagement.
Responsibilities Attend member visits at their primary care provider or specialist office and provide follow-up support for care coordination needs.
Complete comprehensive assessment and person-centered care plans (PCCP) for each member on the assigned caseload.
Manage PCCPs and member contact in compliance with all agency requirements, internal protocols, and accreditation standards.
Develop, implement, and maintain PCCPs using SMART goals.
Maintain up-to-date PCCPs in the electronic health record, including objective measures to track progress toward treatment plan goals.
Provide education with teach-back regarding medical, behavioral, and functional health conditions, symptoms, and treatment options.
Provide evidence-based clinical interventions centered on established PCCP goals using approaches such as trauma-informed care, harm reduction, behavior change modalities, motivational interviewing, teach-back methods, and problem solving.
Meet established Key Performance Indicators.
Manage assigned caseload based on contact frequency requirements and utilization data.
Provide crisis interventions, as appropriate.
Mitigate/resolve barriers to care to increase adherence to treatment plans.
Collaborate with the ICT to update the team on member progress and needs; provide CCM recommendations to stabilize health and address social determinants of health barriers.
Assist members in accessing and engaging with services and resources.
Maintain schedule in the clinical system and document all interactions within 1 business day.
Actively participate in required meetings and follow up on member compliance with service or resource referrals.
Minimum Qualifications Licensed clinician (RN, LCSW, LMSW, LMHC, LPC) by the state in which practicing; CCM credentials preferred. CMGT-BC, CCTM, C-SWCM, C-ASWCM, ACM or FAACM will be considered. Preference given to CCM credentialed candidates.
3+ years of experience serving the needs of complex populations, including medically complex, trauma history, mental health conditions, substance abuse, and socioeconomic barriers in an office or community-based setting. Preference for candidates with experience in multiple settings (inpatient, long-term care, home health, corrections, community programs) and with complex government-sponsored populations (e.g., Medicaid, Medicare).
Willingness to travel to meet members where they are, including specialist offices, outpatient centers, and dialysis centers.
Excellent computer skills (Microsoft Office Suite) and electronic medical record documentation.
Excellent written and oral communication skills to interact with members, families, community stakeholders, and the interdisciplinary team.
Ability to meet accreditation and quality standards (e.g., NCQA, PCMH, HEDIS) by following defined procedures to assess, intervene, and document interactions.
Ability to work independently and exercise strong clinical judgment.
Hold and maintain an active driver’s license and proof of insurance in the state of practice.
Working conditions This job operates in the community and in a professional office environment. Travel to meet members and work between community and office is required.
Physical requirements Ability to communicate clearly and exchange accurate information.
Ability to remain stationary for long periods of time and operate standard office equipment.
Ability to drive a personal motor vehicle.
Ability to occasionally move objects up to 20 lbs.
Direct reports None.
Seniority level Mid-Senior level
Employment type Full-time
Job function Health Care Provider
Industries Hospitals and Health Care