Resp & Qualifications PURPOSE: Provides management and assessment of overall FEP PPO care management program. The ideal candidate will have direct experience with FEP PPO line of business and people leading experience as well as their CCM certification. Implements programs and initiatives to form a comprehensive and cohesive model that effectively identifies high-risk members. Manages the delivery of effective interventions, and tracks/reports outcomes from their program. Manages and evaluates care management services offered and works closely with leadership, physicians/providers, and other service lines.
ESSENTIAL FUNCTIONS:- Manages and develops and maintains quality-improvement programs to optimize patient care for the FEP PPO line of business.
- Collaborates with physicians, nursing and hospital leaders to ensure service expectations are being met.
- Manages care management staff. Develops and leads team.
- Conducts care coordination activities including case management and disease management.
SUPERVISORY RESPONSIBILITY:This position manages people.
QUALIFICATIONS:Education Level: Bachelor's Degree in Nursing, OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.
Licenses/Certifications Upon Hire Required:- Health Services\RN - Registered Nurse - State Licensure and/or Compact State Licensure.
Experience: 5 years' care management experience. 1-year supervisory experience or demonstrated progressive leadership experience.
Preferred Qualifications:- Direct experience with FEP PPO line of business. Certified Care Management (CCM) certification.
Knowledge, Skills and Abilities (KSAs)- Ability to communicate effectively verbally and in writing.
- Knowledge of health benefits industry, products, trends, consumer market, and competitive intelligence.
- Knowledge and proficiency in use of metrics and measures in managing programs and services.
- Strong organizational skills to manage multiple projects, issues and priorities.
- Basic understanding of the strategic and financial goals of a health care system or payor organization, as well as health plan or health insurance operations (e.g. networks, eligibility, benefits).
- Knowledge of managed care principles and concepts including Health Plan Employer Data and Information Sheet (HEDIS) and knowledge of the standards of practice for case managers.
- Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
Salary Range: $99,920 - $185,477
Salary Range Disclaimer The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).
PHYSICAL DEMANDS:The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.
Sponsorship in US Must be eligible to work in the U.S. without Sponsorship
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