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.
- 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 iniatitives.
- 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 Admnistration 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:
- Intermediate Ability to communicate and make recommendations to upper management Assists in evaluating process improvements
- Intermediate Demonstrated time management and priority setting skills
- Intermediate Ability to create, review and interpret treatment plans Ability to create, review and interpret treatment plans
- Intermediate Ability to lead/manage others Demonstrates high level time management and priority setting
- Intermediate Demonstrated problem solving skills
- Intermediate Demonstrated interpersonal/verbal communication skills
- Intermediate Demonstrated negotiation skills Demonstrated negotiation skills
- Intermediate Knowledge of community, state and federal laws and resources Knowledge of community, state and federal laws and resources
- Intermediate Demonstrated written communication skills
- Intermediate Ability to effectively present information and respond to questions from families, members, and providers Strong oral and written communication skills including the ability to effectively present information and respond to questions from families, members, and providers as well as the ability to relate effectively to upper management
- Intermediate Ability to effectively present information and respond to questions from peers and management
- Intermediate Knowledge of healthcare delivery
- Intermediate Ability to lead/manage others in a matrixed environment
- Intermediate Ability to implement process improvements
- Advanced Other Strong clinical knowledge of broad range of medical practice specialties
- Required Licensed Registered Nurse (RN)
- Required Other Maintain required contact hours to fulfill regulatory requirements
- Preferred Certified Case Manager (CCM)
- Required Intermediate Microsoft Outlook Proficient in Microsoft Office including Outlook, Word and Excel
- Required Intermediate Microsoft Word Knowledge of or the ability to learn company approved software such as CRMS, Peradigm, InterQual, Sidewinder and other software in order to perform job duties
- Required Intermediate Microsoft Excel
- Required Intermediate Microsoft PowerPoint
- Required Intermediate Healthcare Management Systems (Generic)
- Required Intermediate Microsoft Visio