Under general direction of the Director, Clinical Services, the Sr. Manager, Case Management and Transition of Care will be responsible for the oversight of Case Management, Disease Management and Transitions of Care programs. The Case and Disease Management programs include Ambulatory Case Management, OB Case Management , Complex Case Management, and Transitions of Care. The Sr. Manager, Case Management and Transition of Care will be responsible for the program development and execution of this unit, budget administration, hiring and managing staff as well as ongoing management and operations of this unit. The Sr. Manager will also promote cost effective care and high quality outcomes by ensuring that all Case Management programs provide timely and excellent care, care coordination, and linkages.
Principal responsibilities include:
Case and Disease Management
· Oversee the programs in Case Management, Disease Management (e.g. Diabetes Management, Asthma Management), Care Coordination, OB Case Management and Complex Case Management.
· Propose, develop, and manage any additional programs and processes to identify and manage high risk members and to improve member’s health outcomes and prevent hospitalizations.
· Assist in writing and implementing business requirements for any software systems that will be used in the assessment, care coordination and case management processes.
· Work with Analytics, Quality and Accreditation, and Compliance Departments to ensure the Case and Disease Management program meets NCQA, state, and federal quality and accreditation standards. Oversee the collection and analysis of data and the creation/revision of standard andn/or new reports.
· Recommend and oversee process and performance improvement for the CM/DM programs. Ensure that all state and federal requirements are supported by the current program policies and IT platforms.
· Implement methods to recruit and retain expert staff including hiring, developing, mentoring, training, and retaining competent staff.
· Monitor the quality and productivity of Case and Disease Management staff.
· Engage internal and external stakeholders in care coordination/case management processes, promote interdisciplinary collaboration, foster teamwork, and champion service excellence in keeping with organizational goals.
· Appropriately manage people, relationships, and processes in order to achieve maximum results.
· Complete and conduct annual performance evaluations with staff
· Develop and manage the departmental budget and track monthly variances. Oversee expense and revenue utilization.
· Provide quality care services measured by consistent achievement of professional standards and the satisfaction of customer expectations.
Transitions of Care
· Work with Manager, Transitions of Care to grow and develop the Transitions of Care Program
· Establish and leverage collaborative relationships with hospitals, care facilities, community case management and PCPs to ensure the needs of the members are met and policies of the plan are followed.
· Work with Manager, Transition of Care, Medical Director, CMO, and other internal and/or external stakeholders to develop and improve ways to anticipate and prevent readmissions and/or inappropriate ED use and to collaborate more effectively on Discharge Planning.
· Oversee continuous quality improvement process for Care Transitions Program to reduce and eliminate unnecessary hospital days and improve member and provider experience.
· Work with Manager, Transitions of Care, Alliance Medical Director and/or CMO to validate patient acuity, plan of care and medical necessity review recommendations
· Participate in weekly internal Alliance rounds
· With the Director, Clinical Services and other medical management leadership team staff, collaborate in implementing and monitoring departmental strategic plans for utilization management and care coordination as they relate to Case Management and Transitions of Care; Work with Unit Managers to develop case load assignments, productivity metrics and meaningful management reports of both activities and outcomes.
· Assure staff and department compliance with all regulatory, contractual and accreditation requirements and provide documentation for audits and reviews, including CMS, DHCS, DMHC, and NCQA.
· Assist the organization with preparation and maintenance of NCQA accreditation.
· Work with various departments at the Alliance to resolve inquiries into claims, authorizations, and eligibility.
· Support and coordinate the day to day department activities by coaching and assisting the clinical and non-clinical staff.
· Provide training, development, and continuing education to staff.
· Maintain professional and technical knowledge.
· Perform other duties as assigned.
ESSENTIAL FUNCTIONS OF THE JOB
· Developing and analyzing systems and processes to achieve quality and efficiency measures.
· Conduct ongoing analysis that results in department changes to boost efficiency and effectiveness and align work processes with department goals and objectives.
· Developing quantitative and qualitative management reports and analyzes data.
· Developing long and short range strategic plans for case and disease management activities.
· Communicating effectively and efficiently internally and externally.
· Supervising and training of staff to include but not limited to team building, evaluations, corrective actions, and progressive discipline procedures.
· Ensure training of staff for key approaches to care, such as Motivational Interviewing, Trauma Informed Care, and Harm Reduction principles
· Writing, reporting, administration, and analysis.
· Developing and making verbal presentations.
· Leading and participating in internal and external committees and meetings.
· Complying with the organization’s Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls
· Constant and close visual work at desk or computer.
· Constant sitting and working at desk.
· Constant data entry using keyboard and/or mouse.
· Extensive typing required.
· Frequent verbal and written communication with staff and other business associates by telephone, correspondence, or in person.
· travel to Care Facilities and/or Hospitals as needed
· Frequent lifting of folders and other objects weighing between 0 and 30 lbs.
· Frequent walking and standing.
Occasional driving of automobiles
EDUCATION OR TRAINING EQUIVALENT TO:
· Registered Nurse license, currently active and unrestricted licensed in the State of California
· Master’s Degree (M.S.N, or M.H.A.) preferred.
· Have a cleared TB test prior to or within seven days of hire.
· Current CPR and first aid card prior to or within six months of hire is preferred.
· Certified Case Manager certification highly preferred
MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:
· Minimum five years’ experience in case management required, preferably in a health care and community-based setting.
· Minimum one years in management level experience for a qualified case management program in a health care and community-based setting required.
SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):
· Knowledge of Medi-Cal preferred.
· Strong utilization management, quality management, and care coordination background and skills.
· Experience with planning, implementing, and evaluating clinical and disease prevention programs.
· Background in population-based community health assessment and interventions.
· Ability to work effectively in a multidisciplinary approach in management.
· Ability to build a strategic plan and operationalize it.
· Ability to build and manage an administrative budget.
· Ability to plan for, hire and supervise staff, and ensure that direct reports supervise staff in a manner that maximizes employee performance and business results.
· Possess very strong coaching/counseling skills including the ability to function as a mentor to management and employees.
· Ability to motivate and train staff and promote and support a positive and collaborative working environment.
· Ability to communicate effectively, both verbally and in writing.
· Ability to handle confidential information with appropriate discretion.
· Basic understanding of regulatory and compliance issues involving case and disease management.
· Ability to work with and use clinical data effectively to improve efficiency and effectiveness of care.
· Ability to make thoughtful decisions and exercise sound judgment.
· Strong financial analytical skills.
· Strong problem solving skills.
· Flexibility and creativity a must.
· Familiarity with programmatic and clinical research strategies in a managed care setting preferred.
· Proficient experience in Microsoft Word, Microsoft Excel, Outlook, and Microsoft PowerPoint.