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Job Summary: The Manager, Care Management is responsible for the mentoring, training and oversight of care coordination and care management staff (i.e. Care Coordinators, Health Coaches, High Intensity Care Managers). Responsible for the development, maintenance of Medical Management workflows, policies and procedures per NCQA/CMS or payer guidelines. Participates in the Case Management workgroup to assure standardized use of appropriate systems or workflows. In conjunction with VP will develop staff productivity and performance metrics, monitor staff adherence to metrics, and recommend workflow or system modifications to address payer contractual needs. Act as a clinical resource, conducting in depth general assessment of High Risk patients, referring to payer care management programs as appropriate. Participates in payer clinical integration rounds and other interdisciplinary rounds, as appropriate.Essential Duty # 1 - Percent: 60%
Management Duties:
Provide on-going education to the care coordination and case management staff related to payer contractual obligations, clinical and quality metrics and associated payer programs.
Assist with the development of care coordination and care management activities that support health plan (i.e., commercial, Medicare Advantage, ACO, CPC+, etc.) contracts requirements.
Monitor production and other dashboard reports through the various systems to support appropriate outcomes.
Audit bi-monthly care management system entries for accuracy and completeness with care coordination or care management process based on payer, i.e., turn-around-time in opening cases, development of care plans, completion of assessment, ensure all Interdisciplinary team members participates in care-plan development based on CMS guidelines, as appropriate.
Assign corrective action plans to staff as indicated for immediate review and resolution.
Participate in health plan clinical coordination and inpatient interdisciplinary rounds. Assist in development of or modifications to of workflow based on health plan contracts.
Interface with Medical Director as needed to discuss difficult clinical issues and any trending of quality or clinical metrics.
Track and trend daily/monthly/quarterly utilization, quality, and retention reports. Review key trends with VP Clinical Programs, key medical management leadership.
Actively participates in internal quality and work flow enhancement projects, and other duties as assigned
Completes monthly reporting as assigned.
Able to work independently and make independent decisions.
Essential Duty # 2 - Percent: 40%
Care Management Duties:
Conduct general assessments based on care coordinator referrals within identified time frames.
Refers appropriate patients to health plan care management staff for on-going High Intensity Case Management.
Engage IPA providers with care coordination/care management activities – i.e. roster review, treatment plan, care plan development, and retention activities.
Qualification Requirements:
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. This job description reflects management's assignment of essential functions, it does not prescribe or restrict the tasks that may be assigned. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Education/Experience:
RN unrestricted license.
Previous supervisory experience.
Previous health plan care management, PCMH care management, and/or Medicare care management experience.
Understanding of Medicare Fee-for-Service benefits
Knowledge of commercial and Medicare Advantage health plan design. Knowledge/Skills/Abilities:
3 – 5 years supervisory experience preferred. Previous experience in HMO, Medical Group or IPA setting with working knowledge of Senior Services.
Experience with Microsoft Programs; PowerPoint, Excel, Word, Outlook.
Maintains member confidence and protects operations by keeping claim information confidential in compliance with HIPPA requirements.Physical Demands:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.While performing this job, the employee is regularly required to sit; use hands to finger, handle, and/or feel; and talk and/or hear. The employee frequently is required to stand and/or walk. The employee is occasionally required to climb or balance and stoop, kneel, crouch, and/or crawl. The employee must regularly lift and/or move up to ten (10) pounds and frequently lift and/or move up to twenty-five (25) pounds. Specific vision abilities required by this job include close vision.Work Environment:
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Vacancy expired!