Leads team of clinicians that deliver case management services to targeted commercial and Medicare member populations with a range of health status/severity and clinical needs. Manages staff resources to ensure effective member outreach and engagement as well as achieving defined clinical and financial outcomes.
Responsibilities
- Analyzes trends and identifies/implements departmental initiatives, from production, quality, financial and audit data.
- Optimizes processes and workflows to achieve successful quality outcomes.
- Leads the development and oversight of key performance indicators and monitors and tracks to independently identify utilization patterns and/or deviation from expected results.
- Oversees the development and implementation of processes and systems to improve the efficiency and effectiveness of case management services.
- Develops effective relationships with key health systems to improve communication, efficiency and effectiveness of case management process including leading clinical meetings to facilitate relationship building and identifying opportunities to advance access to Electronic Medical Records (EMRs)/Portals.
- Oversees the recruiting, performance, development and mentoring of staff.
- Ensures that team members are clinically competent and adequately trained in motivational interviewing and other engagement techniques.
- Provides leadership and support to managers and supervisors.
- Ensures monitoring and tracking tools are in place to adequately link and assess production and quality driven work products and outcomes to individual performers.
- Leads talent management activities to develop and cultivate future leaders.
- Serves as the subject matter expert liaison for case management services and/or leader on cross-functional teams.
- Initiates cross functional/departmental discussions and initiatives to remove barriers and improve communications and workflows.
- Develops formal policies, procedures and workflows that effectively guide work activity.
- Performs other duties as assigned.
Qualifications - External
Qualifications
Education and Experience:
- Bachelor of Science in Nursing required. Master’s degree preferred.
- 8 years progressive experience in managed care case management in a health plan, 5 years of which are in a leadership capacity.
- Experience with Medicare/Medicaid/Self-Funded lines of business.
Professional Certification(s):
- Registered Nurse with current, unrestricted license in state of residency.
- Ability to obtain Ohio RN or Multi-state RN Compact License within 60 days of date of hire.
- Ability to obtain additional RN licensure for multi-state member management.
Technical Skills and Knowledge:
- Comprehensive knowledge of health plans, NCQA accreditation standards and CMS regulations, HIPAA compliance and the ability to apply advanced concepts to Company operations.
- Strong knowledge of health insurance benefits, care delivery processes, continuum of acute through post- acute care, and network plan designs.
- Strong knowledge of clinical claim management including ICD 10, CPT and HCPCS codes
- Strong communication and presentation skills.
- Intermediate to advanced proficiency with Microsoft Office, including Outlook, Excel, PowerPoint, Word, and electronic medical records systems.
