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.
Reports to: Medicare Executive Director
Department: Tennessee Executive State
Position location: Brentwood, TN
- 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.
- Required A Bachelor's Degree in Nursing, Health Administration or directly related field
- Required 10 years of experience in current case management
- Required 5 years of management experience
- Required 5 years of experience in managed care
Licenses and Certifications:
- 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
A license in one of the following is required:
- Licensed Registered Nurse (RN) or Licensed Clinical Social Worker (LCSW) license is required.
- Certified Case Manager (CCM) is preferred
- Maintain required contact hours to fulfill regulatory requirements is required
- Required Intermediate Microsoft Outlook
- Required Intermediate Microsoft Word
- Required Intermediate Microsoft Excel
- Required Intermediate Microsoft PowerPoint
- Required Intermediate Healthcare Management Systems (Generic)
- Required Intermediate Microsoft Visio