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Manager-Care Management Medicaid

Company: PacificSource Health Plans
Location: Salem
Posted on: September 12, 2019

Job Description:

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 geographic regions.
  • 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 profitability goals.
  • 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 management.
  • 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, etc.
  • 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 Responsibilities:
  • Meet department and company performance and attendance expectations.
  • Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
  • 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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