Under general direction of the Director, Clinical Services, the Manager, Case Management will be responsible for the oversight of Case Management and Disease Management programs (including Ambulatory Case Management, OB Case Management and Complex Case Management) with a focus on the member’s medical history and needs. This position will oversee members’ needs by providing the necessary medical and community outreach resources to promote cost effective care with quality outcomes. The Manager, Case Management will also be responsible for the development and execution of this unit, budget administration, hiring and managing staff as well as ongoing management and operations of this unit and its processes.
Principal responsibilities include:
· Oversee the programs in Case and Disease Management (e.g. Diabetes Management, Asthma Management etc), Care Coordination, OB Case Management and Complex Case Management.
· Identify, develop, and manage any additional programs and processes to identify and manage high risk members 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.
· Oversee the collection, analysis, and reporting of Case and Disease Management based on NCQA, state, and federal standards. Recommend 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 intake and assessment, care coordination and case managers’ productivity.
· 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.
· Provide education and promote understanding of care coordination, case management, social services, and quality improvement issues.
· Participate on compliance, finance, contracting, regulatory, and other multidisciplinary committees that foster organizational improvement.
· Anticipate, identify, and analyze care issues and trends, make appropriate recommendations, develop and implement best practice pilot projects aimed at reducing medical costs and improving quality healthcare outcomes.
· Work closely with the Alliance management team to identify medical and social services issues that have an impact on plan benefits and their administration.
· Review quality concerns identified through the QI process and oversee the implementation and monitoring of relevant corrective action plans.
· Prepare for and participate in regulatory audits and develop and monitor corrective actions plans.
· Oversee department workload and ensure that timely and effective adjustments are made to ensure timely service to members.
· Oversee the development of policies and procedures and any necessary case management protocols.
· Administer a program for the development, preparation and maintenance of appropriate and required records, data, processes, policies and procedures.
· Complete other duties and special projects as assigned.
EDUCATION OR TRAINING EQUIVALENT TO:
· BSN or MSN required.
· Registered Nurse license, active and unrestricted licensed in the State of California.
· Administrative Master’s Degree preferred (MPA, MBA, MSN, MPH or other applicable master degree)
· 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.
· Certification in applicable area preferred or willing to become certified within 12 months of hire or a date agreed to by supervisor.
MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:
· Three to five years healthcare related experience preferred.
· Up to 5 years’ experience working within the managed care/care management environment.
· Two to three years managerial /supervisory experience in health care preferred.
SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):
· Knowledge of Medi-Cal and/or Department of Health Services and/or Medicare regulations and standards a plus.
· Ability to motivate, train, and supervise.
· Ability to make thoughtful decisions and exercise sound judgment.
· Experience with planning, implementing, and evaluating clinical and disease prevention programs a plus.
· Background in population-based community health assessment and interventions preferred. .
· Ability to work effectively in a multidisciplinary approach in management.
· Ability to communicate effectively, both verbally and in writing.
· Experience in use of Microsoft Office suite.