Responsibilities Learn more at: https://prominence-health.com/
Job Summary: This position is responsible for the day-to-day management of the Care Management (CM) program, D-SNP Care Management Program, and Transitions of Care. The position entails staff supervision and personnel management in the department. The Clinical Manager is responsible for the implementation of and management of a comprehensive Care Management and Transitions of Care Program.
The Clinical Manager is responsible for the implementation, and management of a comprehensive Case Management program that is accountable for the management of members with catastrophic/complex conditions. The Clinical Manager is responsible for managing a staff of Registered Nurses, Licensed Clinical Social Workers, and non-clinical staff, who utilize the Case Management process to 1) assess the health care needs of the member; 2) develop a comprehensive treatment plan complete with specific goals and objectives; 3) implement a treatment plan in collaboration with the PCP and the other providers involved in the patient's care; 4) negotiate and coordinate services for the patient; 5) monitor and evaluate the effectiveness of the plan in achieving the goals and objectives; and 6) change and modify the plan as needs and situations change. The Clinical Manager is responsible for ensuring that staff are appropriately trained and deployed to support the needs of Prominence Health Plan and its members. The Clinical Manager will develop policies, procedures, workflows, and processes to ensure comprehensive Care Management and Transitional Care services are available to Prominence members. The Clinical Manager ensures that all staff within the department adhere to the CMSA Standards of Practice for Case Management.
Additional responsibilities include ensuring that the D-SNP CM program in the model of care (MOC) meets or exceeds regulatory and accreditation requirements for the Centers for Medicare and Medicaid Services (CMS), state Medicaid offices (as relevant), and NCQA, and leads all efforts associated with the successful operation of a CM program. The Clinical Manager is responsible for interacting with hospital case management/discharge planners to ensure that they are informed about the Prominence TOC program and the Prominence expectations for collaboration in the care continuum process .
Benefit Highlights:- Loan Forgiveness Program
- Challenging and rewarding work environment
- Competitive Compensation & Generous Paid Time Off
- Excellent Medical, Dental, Vision and Prescription Drug Plans
- 401(K) with company match and discounted stock plan
- SoFi Student Loan Refinancing Program
- Career development opportunities within UHS and its 300+ Subsidiaries! • More information is available on our Benefits Guest Website: benefits.uhsguest.com
Qualifications Qualifications and Requirements:- Registered Nurse with a BSN or MSN degree
- Active, unrestricted, current, and valid RN licenses in the States of Practice (Nevada, Texas and/or Florida).
- Certified Case Manager (CCM) or Certified Professional in Healthcare Quality (CPHQ), or ability to obtain within the required time.
- Minimum Five (5) years of management experience in a managed care environment. Equivalent combination of education and experience will be considered.
- Recent (within past 3 years) working knowledge of Milliman Care Guidelines, preferred.
- Minimum of five years (5) in clinical medical/surgical nursing practice within a hospital setting, preferred.
- Ability to effectively communicate in English (Nevada, Texas, and Florida markets), Spanish (Texas and Florida markets), and/or Spanish, French Creole, and/or Tagalong (Florida market), both verbally and in writing depending on the State of RN licensure and employment location.
- Experience executing strategies; organizing and prioritizing multiple projects and relationships with key stakeholders and program implementers.
- Written and oral communication skills, including large and small group presentations, group facilitation and training.
- Ability to influence others and work collaboratively with key partners to achieve positive results.
- Ability to present ideas and programs to key strategic alliances, professional volunteers, and funding partners.
- Computer Skills: Smartsheet, SharePoint, Microsoft Office (Word, Excel, PowerPoint), and database software.
- Empathetic, Caring, Compassionate Listener.
- Able to work with a diverse multicultural and socioeconomic population.
- Familiarity with health care delivery and/or health insurance programs.
- Knowledge of medical terminology.
- Strong problem-solving and critical thinking skills.
- Experience working with the Medicare and Medicaid population segment preferred.
- Knowledge of Medicare/ Medicaid processes and compliance standards
- Ability to travel local and regional up to 25-50% of time .
