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.
Department: Health Services State
Reports to: Sr. Director, MLTSS
Additional Responsibilities:Candidate Education:
- 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.
- Required A High School or GED
- Preferred A Bachelor's Degree in nursing
- Required 5 years of experience in case Management, Home care or geriatrics
Licenses and Certifications:
- 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
A license in one of the following is required:
- Required Licensed Registered Nurse (RN)
- Preferred Certified Case Manager (CCM)
- Required Intermediate Microsoft Word Computer literate
- Required Intermediate Microsoft Excel
- Required Intermediate Healthcare Management Systems (Generic)
- Required Intermediate Microsoft Outlook
- Preferred Other bilingual