Maintains operational accountability for care coordination, case management, disease management, health promotion and peer support functions to achieve the business and clinical outcomes for the health plan, meeting contract requirements. Directs all care coordination activities ensuring delivery is consistent with model of care, approved program descriptions and meets state, National Committee of Quality Assurance (NCQA) accreditation standards, Centers for Medicare and Medicaid Services (CMS), and other applicable standards and requirements.
-Plans, implements, directs and provides leadership and oversight of the clinical and care coordination operational processes and staff.
-Actively participates in cost of care and medical action plan activities.
-Actively participates in regulatory, quality management, performance management and accreditation activities.
-Acts as Subject Matter Expert for case coordination and care management programs that care coordination and care management team activities meet the standards required for the state, NCQA, CMS and other accreditation and oversight entities.
-Directs, coordinates and oversees the evaluation of efficiency and productivity of care coordination functions, including complex case management, chronic disease programs, health promotion for physical and behavioral health as well as the work of peer support specialists and health guides.
-Assures staff selection, training, and evaluation to promote the development of a high quality team.
-Collaborates and coordinates with departmental managers to integrate and communicate with and across the utilization management and quality programs.
-Participates in the evaluation of the care coordination program against quality and utilization benchmarks and goals. Identifies opportunities for improvement.
-Works closely with and provides input to national health plan clinical team on program design, policies, procedures, workflows, and correspondence.
-Collaborates with leaders inNetwork, Community Liaison, Quality Improvement, Customer Service and Finance to assure a comprehensive approach to managing quality of care, service and cost of care.
Bachelors: Nursing (Required)
License and Certifications - Required
RN -Registered Nurse, State and/or Compact State Licensure - Care Mgmt
License and Certifications - Preferred
CCM - Certified Case Manager - Care Mgmt
Other Job Requirements
Accreditation and Quality Improvementexperience., Minimum5years managed care and Medicaidexperience. Minimum3years direct supervisoryexperience including responsibility for analyzing cost of care results, cost of care opportunities, quality measurement and performance metric development and achievement., Must haveexperience overseeingcontractual performance standards.Experience withreporting and analyzing managed careutilization data. Must2+yearsexperiencein care coordination and case management operations.