Ensures the case management process of assessing, planning, implementation, coordination, monitoring, and evaluating services and outcomes is pursued to maximize the health of the member. Oversees the socio economic needs and services of selected member populations across the continuum of illness. Takes part in extensive community outreach to garner relationships with key stakeholder groups and organizations.
Department: IL-Health Services-State
Reports to: VP, Field Health Services
Location: Chicago, IL (N. Wacker Dr)
- Manages and develops direct reports who conduct both case management and social service functions within a member's care plan.
- Sets operational priorities and manages resources to operational goals and budgets.
- Proactively monitors appropriate metrics to drive up efficiency.
- Directs the case management process, providing advice when necessary of complex, controversial and/or unique administrative processes, medical procedures and payment guidelines.
- Establish, maintain and foster professional working relationships with all providers and community stakeholders.
- Partners & collaborates with other departments cross functionally regarding care and case management and/or Health Service initiatives.
- Manages & resolves e-mails and escalated phone issues in response to provider, staff and other department requests.
- Directs work assignments, measures results and initiates personnel actions as required.
- Participates in continuous quality improvement projects that involve case and social service components.
- Ensure timely and complete delivery of required regulatory reports.
- Serve on community advisory boards and task forces to address workforce and other long-term care challenges.
- Ensures compliance with all state and federal regulations and guidelines for all lines of business.
- Performs other duties as assigned.
- A Bachelor's Degree in Nursing, Health Administration or directly related field is required
- 10 years of experience in current case management is required
- 5 years of management experience is required
- 5 years of experience in managed care is required
- Ability to communicate and make recommendations to upper management
- Demonstrated time management and priority setting skills
- Ability to create, review and interpret treatment plans
- Ability to lead/manage others
- Demonstrated problem solving skills
- Demonstrated interpersonal/verbal communication skills
- Demonstrated negotiation skills
- Knowledge of community, state and federal laws and resources
- Demonstrated written communication skills
- Ability to effectively present information and respond to questions from families, members, and providers
- Ability to effectively present information and respond to questions from peers and management
- Knowledge of healthcare delivery
- Ability to lead/manage others in a matrixed environment
- Ability to implement process improvements
- Strong clinical knowledge of broad range of medical practice specialties
Licenses and Certifications:
- Licensed Registered Nurse (RN) is required
- Maintain required contact hours to fulfill regulatory requirements is required
- Certified Case Manager (CCM) is preferred
- Intermediate proficiency with Microsoft Outlook, Word, Excel, Visio and PowerPoint is required
- Intermediate proficiency Healthcare Management Systems (Generic) is required