Manager - Care Coordination for Government Programs ( Medicare / Medicaid )
To lead, coach, direct and assume responsibility for the day-to-day functions of the Case Management. Assumes responsibility to address the needs of Medicaid and Medicare members with chronic health conditions. Collaborate with other relevant MHP departments, providers and community leaders to establish interventions.
PRINCIPAL DUTIES AND RESPONSIBILITIES:
- Ensure compliance with the National Committee for Quality Assurance (NCQA), Michigan Department of Community Health (MDCH), Centers for Medicare and Medicaid Services (CMS) and other regulatory bodies. Implement Medical Management quality improvement plans as appropriate. Assist in the preparation for accreditation and regulatory reviews as it relates to Medical Case Management.
- Research, develop, implement and update policies and procedures specific to Case Management.
- Participate on interdepartmental workgroups to coordinate policies and procedures related to Healthcare Management. Ensure that policies and procedures are consistent with departmental and corporate goals and objectives.
- Utilize evidence-based, clinically relevant research information to develop such policies and procedures, including government, academic, external quality review organizations and Internet sources.
- Coordinate the development of ad hoc clinical and professional groups that support the development of policies and procedures.
- Perform regular reviews of criteria, policies and procedures.
- Coordinate and monitor all department activities. Ensure adequate staffing and service levels. Responsible for the selection, training and development of personnel. Coach, motivate, empower and monitor performance of team members.
- Monitor and measure the performance of Case Management staff as it pertains to productivity and adherence to policies and procedures. Implement corrective actions, as indicated. Orient and train new employees and provide ongoing staff development, including inter-rater reliability. Ensure that production and performance of direct report staff meets contract and company expectations and compliance regulations.
- Act as an information and problem-solving resource for team members, physicians, hospitals and other departments. Interact with Medical Directors as required for the case management program content, provider interactions and case resolution. Provide program reports for leadership and peers as necessary.
- Coordinate in-services, meetings and communications with team members and otherHealthcare Management and HAP Leadership, as necessary.
- Ensures all documentation meets minimum contract guidelines and is clinically appropriate to the member needs through management oversight activities including but not limited to member chart reviews.
- Addresses and assures gaps in care are identified and addressed including but not limited to HEDIS measures and five-star ratings.
- Identifies high risk members and assures appropriate care coordination activities
- Ensures safe and appropriate transitions of care.
- Monitors and addresses admission, re-admission and ED activity and ensures targeted care coordination to reduce re-admissions.
- Ensures development and accuracy of team dashboard reporting utilizing data within spreadsheet and chart reports
- Monitors employee dashboard activity including but not limited to review and follow up of employee daily production reports, external compliance reports, admission and discharge activity reporting, financial high cost member.
- Maintain professional relationships with the provider community. Analyze delivery system, network and physician performance against practice guidelines to identify opportunities for improvement.
- Maintain knowledge of current practices and trends in Case Management.
- Perform additional duties as needed.
- Registered Nurse with:
- Valid RN license in state of Michigan
- Bachelor’s Degree in related field.
- Minimum of 5 years of Care Management experience
- Minimum of two (2) years of administrative/management experience in an HMO, hospital or other health care agency.
- Minimum of two (2) years of experience in Managed Care.
- Minimum of one (1) yearexperience in program planning and implementation that supports managed care principles.
- Strong leadership and delegation skills
- Superior communication and conflict management skills allowing for the management of complex issues with effective diplomacy
- Written and interpersonal communication skills
- Strong problem solving, analytical and decision making
- Strong organizational, planning and implementation
- Well-developed time management and prioritization
- Creative and resourceful
- PC literacy
- Demonstrated strong skill set in Microsoft Outlook, Word, Excel, Visio and Adobe programs
- Strong skillset in electronic health record, case management.
- Ability to identify, assesses, and solve highly complex problems relating to team dynamics, benefits administration, and the delivery of health services
- Knowledge of the health care industry, health maintenance organizations and third- party reimbursements.
- Knowledge of national standards related to case management goals, strategies and measurement.
- Medical management processes across the continuum of care
- Standard medical procedures/practices and their application as well as current trends and developments in medicine and nursing
- Disease processes and recognition of their distinctive cost patterns and unique range of available therapies and interventions
- Local/national community resources
- Medical terminology and ICD-10 and CPT coding
- HMO, POS, PPO benefits and program requirements as relates to medical management preferred
- State and Federal Medicaid and Medicare regulations
- Demonstrated program success within a managed care organization
- Demonstrated success of leadership skills and experience that emphasize trust, relationship building and professional growth of support staff