The incumbent will be responsible for managing a caseload and leading a team of behavioral health care managers and field support staff delivering office-based, embedded, and field-based case management and care coordination services to identified high risk patients such that WellCare achieves its quality of care, cost, and patient satisfaction goals. Incumbent will work closely with clinical consultants including, but not limited to nutritionists, pharmacists, nurse practitioners, and supportive care specialists. They will also train, and delegate work to the appropriate staff level and ensures delivery of care and service in alignment with federal and state regulatory requirements and scope of practice for clinical position. The primary objective of this position is to identify and resolve social issues to maximize the opportunity that assigned patients can live at home, safely, adhere to appropriate medications, are actively connected with his/her primary care physician, and if appropriate, be compliant with a well-developed patient care plan. Critical measures of success are compliance with CMS and WellCare policies, eliminating avoidable admissions, reducing ER visits and readmissions and achieving a high degree of medication adherence and patient centric care plans.
Reports To: Director ACO
Department: Health Services
Position Location: Atlantic City / Telecommute
Additional Responsibilities:Candidate Education:
- In-home/facility and telephonic case management for high risk behavioral health members.
- Supports staff in all of their care management activities.
- Leads the daily activities of the office-based, embedded, and field behavioral health staff, including appropriate referral and caseload assignments in alignment with employee licensure, experience, and capabilities.
- Improves team's strategies around locating, engaging, assessing, and managing assigned members.
- Continuously evaluates, reports, and implements improvements to impact staff productivity and quality of performance through available telephonic and medical management applications and supportive data analysis and outcomes reporting.
- Ensures the responsible and professional delivery of comprehensive service and care delivery of the field care management including the facilitation of relationships with community resources.
- Coordinates and facilitates member's hospital stay and discharge needs.
- Collaborates with healthcare providers on the behavioral health and socio-economic aspects of care plan.
- Responsible for the ongoing assessment, intervention, and resolution of member's needs (psychosocial, ADL/IADL, DME, rehab services, transportation, environmental needs, and other identified barriers to care).
- Identifies and facilitates members appropriate for supportive care.
- Instruction on how to access program resources and staff, provider, and community resources.
- Leads interdisciplinary case reviews for collaborative assessment and coordination planning to ensure quality of care.
- Monitors activity of office-based, embedded, and field care management team through monitoring efforts (e.g. ride along, case reviews, case audits, call monitoring, etc.)
- Performs performance management reviews and HR oversight of assigned personnel.
- Promotes positive team atmosphere by demonstrating the ability to work within a team and support team efforts.
- Supervises the quality management activities including quality measures education and GPRO submissions.
- Demonstrates and facilitates customer service excellence.
- Participates in departmental and company in-services as appropriate.
- Complies with all guidelines established by the Centers for Medicare and Medicaid (CMS) and guidelines set forth by other regulatory agencies, where applicable, and defined in WellCare policies and procedures.
- Performs other duties assigned by Manager or Supervisor.
- Required A Bachelor's Degree in Health Care, Behavioral Heath, or related field
- Preferred A Master's Degree in Health Care, Behavioral Health, or related field
- Required 3 years of experience in clinical experience as RN
- Required 3 years of experience in Utilization management and/or case/disease management experience within a hospital, skilled nursing facility, or managed care company
- Preferred Other Experience with a major health plan and/or medical practice with Medicare/Medicaid exposure required acting as a team lead, with Accountable Care Organization experience strongly preferred
Licenses and Certifications:
- Intermediate Ability to work in a matrixed environment
- Intermediate Demonstrated project management skills
- Intermediate Demonstrated interpersonal/verbal communication skills
- Intermediate Other Strong Facilitation and presentation skills
- Intermediate Other Ability to analyze and interpret clinical data in order to coordinate the clinical program
A license in one of the following is required:
- Required Licensed Registered Nurse (RN)
- Required Other Certified Case Manager (CCM) Certification Required within 1 year of hire
- Required Intermediate Microsoft Excel
- Required Intermediate Microsoft Outlook
- Required Intermediate Microsoft Word
- Preferred Intermediate Microsoft PowerPoint
- Required Intermediate SharePoint
- Preferred Intermediate Adobe Acrobate
- Preferred Intermediate Other skills with Care Coordination Programs, and other reporting based tools