This position is responsible for the successful implementation and ongoing case and utilization management activities for HAP. These responsibilities include, but are not limited to oversight, implementation, and evaluation of the Medical Case Management program. It includes staff oversight, process design, outcomes analysis, performance improvement, tactical planning, and the coordination of internal and external resources in support of corporate objectives.
Principal Duties and Responsibilities:
- Assist in the development of the strategic course for the Care Management and Outcomes department.
- Ensure implementation of the Care Management and Outcomes strategic plan and act as a liaison for internal departments, external providers, and community representatives.
- Ensure compliance with the National Committee for Quality Assurance (NCQA), Michigan Department of Community Health (MDCH), Centers for Medicare and Medicaid (CMS), as well as other regulatory bodies. Implement Care Management and Outcomes quality improvement plans, as appropriate. Assist in the preparation for accreditation and regulatory reviews as it relates to Care Management and Outcome’s programs.
- Maintain and revise the Care Management and Outcomes Program Descriptions, Work Plans, annual Program Evaluations, departmental goals and tactical plan, as related to the department.
- Research, develop, implement and update policies and procedures specific to Care Management.
- Participate on interdepartmental workgroups to coordinate policies and procedures related to Care Management and Outcomes. 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.
- Respond to Request for Information (RFI) proposal questions related to Care Management and Outcomes.
- Identify opportunities to improve accessibility of services and availability of providers, working in collaboration with Provider Network Development to implement changes, as appropriate.
- Develop, monitor and evaluate the effectiveness of Care Management and Outcomes department initiatives, including Medical Case Management outcomes measures.
- Collect and analyze data and reports and identify issues or trends affecting case management, utilization, quality and/or provider and physician practice patterns.
- Monitor and measure the performance of Care Management and Outcomes 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 efficient and effective department operations, including oversight of appropriate staffing and assignments.
- Represent HAP in community initiatives and on internal and external committees as necessary.
- Provide support for staff, as needed.
- Other duties as assigned.
Education / Experience Required:
- Bachelor’s degree in Business Administration, health care management or related health care field required. Master's degreepreferred.
- Minimum of five (5) years of administrative experience in an HMO, hospital or other health care agency required
- Minimum of three (3) years of experience in Managed Care required
- At least two (2) years of supervisory or leadership experiencerequired
- Minimum of one (1) yearexperience in case management required
- Minimum of one (1) yearexperience in program planning and implementation that supports managed care principles required
- Registered Nurse with a current Michigan license.
- Certified Case Manager preferred
- Strong leadership and delegation
- Superior communication and conflict management skills allowing for the management of complex issues with effective diplomacy
- Excellent written and interpersonal communication skills
- Excellent documentation
- Excellent customer service
- Strong problem solving, analytical and decision making
- Strong organizational, planning and implementation
- Well developed time management and prioritization
- Creative and resourceful
- Organizational skills required to manage priorities as dictated by business needs
- PC literacy
- 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.
- Managed care philosophy, policies, and procedures
- Knowledge of 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-9 and CPT coding
- HMO, POS, PPO benefits and program requirements as relates to medical management preferred
- State and Federal HMO regulations
- Personnel policies and procedures
- Accreditation standards and regulatory compliance
- 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