Mgr, LTC Clinical Programs

Manager, LTC Clinical Programs-Chicago-IL:

Supports the Clinical Director of Managed Long Term Care (MLTC) Program in reaching or exceeding organizational growth targets for the MLTC Program. Acts as the Clinical Enrollment expert in interpreting Human Resources Administration (HRA) requirements and ensures that all MLTC staff is in compliance with said requirements.

Reports to: Senior Director MLTC Operations

Department: HealthCare Services

Position Location: Chicago, IL

Essential Functions:

  • Conducts quality reviews of SOE and periodic reassessment SAAMs to ensure personalized plans of care are being developed according to approved medical necessity criteria and WellCare designated criteria along with current clinical knowledge.
  • Ensures SOE SAAMs are completed correctly and submitted timely to HRA each month.
  • Ensures that all prospective members are eligible for participation in the Medicare/Medicaid program and that existing members remain eligible.
  • Refers prospective members, who do not have Medicaid, to the Medicaid Applications team.
  • Conducts periodic home visit(s) with Clinical Enrollment staff to monitor their knowledge of Program eligibility criteria and benefits and design.
  • Develops tools to monitor staff productivity and efficiency/efficacy of department policies and procedures.
  • Identifies opportunities for staff development, e.g., sales training, specific disease management protocols.
  • Adheres to all HIPPA standards and confidentiality requirements.
  • Manages MLTC Enrollment Staff.
Additional Responsibilities:
    Candidate Education:
    • Required A High School or GED
    • Preferred A Bachelor's Degree in nursing
    Candidate Experience:
    • Required 5 years of experience in case Management, Home care or geriatrics
    Candidate Skills:
    • Intermediate Ability to effectively present information and respond to questions from families, members, and providers
    • Intermediate Ability to effectively present information and respond to questions from peers and management
    • Intermediate Ability to influence internal and external constituents
    • Intermediate Ability to represent the company with external constituents
    • Intermediate Ability to work as part of a team
    • Intermediate Ability to work in a matrixed environment
    • Intermediate Ability to lead/manage others
    • Intermediate Demonstrated customer service skills
    • Intermediate Demonstrated interpersonal/verbal communication skills
    • Intermediate Demonstrated negotiation skills
    • Intermediate Knowledge of healthcare delivery
    • Intermediate Knowledge of community, state and federal laws and resources
    Licenses and Certifications:
    A license in one of the following is required:
    • Required Licensed Registered Nurse (RN)
    • Preferred Certified Case Manager (CCM)
    Technical Skills:
    • Required Intermediate Microsoft Word Computer literate
    • Required Intermediate Microsoft Excel
    • Required Intermediate Healthcare Management Systems (Generic)
    • Required Intermediate Microsoft Outlook
    • Preferred Other bilingual

    About us
    Headquartered in Tampa, Fla., WellCare Health Plans, Inc. (NYSE: WCG) focuses exclusively on providing government-sponsored managed care services through Medicaid, Medicare Advantage and Medicare Prescription Drug Plans to families, children, seniors and individuals with complex medical needs. WellCare is a Fortune 500 company, and in 2018, was recognized as a Fortune "World's Most Admired Company", ranking in the top five among the health insurance and managed care industry-a testament to the hard work and dedication of the company's nearly 9,000 associates who each day live WellCare's values and deliver on its mission to help its members live better, healthier lives. The company serves approximately 4.4 million members nationwide as of Dec. 31, 2017. For more information about WellCare, please visit the company's website at EOE: All qualified applicants shall receive consideration for employment without regard to race, color, religion, creed, age, sex, pregnancy, veteran status, marital status, sexual orientation, gender identity or expression, national origin, ancestry, disability, genetic information, childbirth or related medical condition or other legally protected basis protected by applicable federal or state law except where a bona fide occupational qualification applies. Comprehensive Health Management, Inc. is an equal opportunity employer, M/F/D/V/SO.