Manager-Care Management Medicaid
Company: PacificSource Health Plans
Posted on: September 12, 2019
This position is reports to the Director of Care Management. This
position is responsible for building and implementing an
evidence-based care management strategy that delivers on the Triple
Aims of improving the member experience, clinical/quality outcomes,
and reducing cost of health care. This position oversees the daily
operations of CM (Medicaid), including supervision of the CM Team
(clinical and nonclinical, and Behavioral Health clinicians)
involved in care coordination and case management functions within
a specific CCO Region/s. This position will have a strong emphasis
on integrating efforts across teams, programs and improvement
activities for all lines of business to promote optimal
organizational effectiveness and enhance performance. Key focus is
on advancing our Care Management program in collaboration with key
provider partners across geographic regions.
- Responsible for ongoing development and implementation of the
Care Management Program with an emphasis on our regional approach.
Ensures alignment with our Population Health Strategy (PH) with a
goal to optimize efforts to maximize the clinical/quality outcomes
of our members.
- Accountable for the continued development and oversight of the
Care Management team (clinical and nonclinical) and across multiple
- Serve as key driver and participant to advance our clinical
workstreams with key provider/community partners to ensure CM
efforts are complimentary and improving clinical/quality outcomes
and improving member experience.
- Support corporate strategic plan ensuring integration and
alignment with Population Health, Quality and support of growth and
- Accountable for ensuring compliance with applicable state and
federal requirements for Commercial, Medicare and Medicaid
including but not limited to NCQA Accreditation, Oregon Health
Authority, policies and procedures and audits.
- Perform analysis of data and best practices to drive the
development and implementation of new programs and processes to
support ongoing success of department goals and initiatives,
including but not limited to; ongoing activities related to
physical and behavioral health integration and the development of a
cohesive team approach to care management.
- Manage change and encourage innovation utilizing LEAN
methodologies for continuous improvement including visual boards
and frequent huddles to monitor key performance indicators and
identify improvement opportunities.
- Work collaboratively with the Utilization Management and
Medical Directors to support the prior authorization, concurrent
review and discharge planning needs for members engaged with care
- Leverage care management platform to oversee team productivity,
optimize workflows and track overall value of care management
programs including member and population outcomes.
- Maintain strong and collaborative relationships with the
leadership of internal and external stakeholders (e.g. Utilization
Management, Quality, Provider Network, IT, Operations, Customer
Care, Provider Partners, and other identified stakeholders) to
address all aspects of Care Management.
- Act as a strategic liaison with community partners and
providers within the assigned CCO region in collaboration with
other department leaders within the organization such as population
health, utilization management, provider network, pharmacy,
- Assist with annual budget development and demonstrate strong
oversight and discipline related to budget vs actual.
- Actively participate in various strategic and internal
committees in order to disseminate information within the
organization and represent company philosophy.
- Performs employee management responsibilities to include, but
are not limited to: involved in hiring and termination decisions,
coaching and development, rewards and recognition, performance
management and staff productivity. Supporting
- Meet department and company performance and attendance
regulations concerning confidentiality and security of protected
- Perform other duties as assigned.
- Facilitate the provision of exceptional customer service to
members, providers, employers, agents, and other external and
internal customers. Ensure that the delivery of services meet
acceptable standards and company and customer expectations. Work
Experience: 5 years clinical experience required. A minimum of 3
years direct health plan experience in case management, utilization
management, or disease management, or equivalent preferred. Prior
supervisory or management experience required. Education,
Certificates, Licenses: Registered Nurse or Licensed Clinical
Social Worker or other licensed healthcare or behavioral health
care clinician, with current appropriate state license or
educational equivalent. Certified Case Manager Certification, or
equivalent, is strongly desired or willingness to obtain
certification within 2 years of hire. Knowledge: Thorough knowledge
and understanding of medical and behavioral health procedures,
diagnoses, treatment modalities, procedure codes, including ICD-9 &
10, DSM-IV & V, CPT codes, health insurance and State of Oregon
mandated benefits. Knowledge of community services, providers,
vendors and facilities available to assist members. Strong
knowledge of health insurance; including managed care products as
well as state mandated benefits. Ability to develop, review and
evaluate utilization and care management reports. Experience in
adult education preferred. Proficient in the use and implementation
of the following tools and concepts across all teams within scope
and accountability: Training, Coaching, Strategy Deployment, Daily
Operations, Visual Management, Operational Improvement & Team
Building/Development. Competencies Our Values
- Building Trust
- Building a Successful Team
- Aligning Performance for Success
- Building Partnerships
- Customer Focus
- Continuous Improvement
- Decision Making
- Facilitating Change
- Leveraging Diversity
- Driving for Results
- We are committed to doing the right thing.
- We are one team working toward a common goal.
- We are each responsible for our customers' experience.
- We practice open communication at all levels of the company to
foster individual, team and company growth.
- We actively participate in efforts to improve our
communities-internal and external.
- We encourage creativity, innovation, continuous improvement,
and the pursuit of excellence. Environment: Work inside in a
general office setting with ergonomically configured equipment.
Travel is required approximately 20% of the time. Physical
Requirements: Stoop and bend. Sit and/or stand for extended periods
of time while performing core job functions. Repetitive motions to
include typing, sorting and filing. Light lifting and carrying of
files and business materials. Ability to read and comprehend both
written and spoken English. Communicate clearly and effectively.
Diversity and Inclusion: PacificSource values the diversity of the
people we hire and serve. We are committed to creating a diverse
environment and fostering a workplace in which individual
differences are appreciated, respected and responded to in ways
that fully develop and utilize each person's talents and strengths.
Disclaimer: This job description indicates the general nature and
level of work performed by employees within this position and is
subject to change. It is not designed to contain or be interpreted
as a comprehensive list of all duties, responsibilities, and
qualifications required of employees assigned to this position.
Employment remains AT-WILL at all times. PacificSource is an equal
opportunity employer. All qualified applicants will receive
consideration for employment without regard to status as a
protected veteran or a qualified individual with a disability, or
other protected status, such as race, religion, color, national
origin, sex, sexual orientation, gender identity or age.
Keywords: PacificSource Health Plans, Salem , Manager-Care Management Medicaid, Executive , Salem, Oregon
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