Job Summary:
Develops, implements and evaluates the services provided by care management department. Enhances the quality of member management by promoting continuity of care and cost effectiveness through whole person in-patient and out-patient management, care integration, case management, utilization review and care planning. Supervises and directs the activities of various levels of assigned personnel using both professional and supervisory discretion and independent judgment.
Job Requirements:
Education and Work Experience:
- Bachelor's Degree in nursing or equivalent combination of education/related experience: Required
- Master's Degree: Preferred
- Five years' nursing experience: Preferred
- One year's leadership experience in a physician clinic, hospital department or health plan setting: Preferred
- Certified Case Manager: Preferred
Licenses/Certifications:
- Registered Nurse (RN) licensure in the state of practice: Required
Essential Functions:
- Partners with internal and external physician advisors, as well as claims department and data management and analytics department to provide safeguards, processes and expected outcomes for the Health Plan's member population. Provides formal and informal education to physicians and the care management team to improve processes and outcomes related to utilization review, case management and compliance. Develops and maintains positive relationships with customers internal and external.
- Works collaboratively with physicians, staff and service line leadership on quality and performance improvement activities related to optimal utilization of resources, efficient delivery of high quality care, patient flow, capacity management and other clinical cost reduction initiatives. Communicates changes that could affect the discharge plan of care.
- Manages communication related to discharge planning and utilization management. Performs ongoing collaboration with staff to ensure condition meets medical necessity criteria.
- Exercises independent judgment in recruiting, training, coaching, supervising and responsibly directing assigned staff.
- Performs other job-related duties as assigned.
