This job manages and coordinates the supervisory staff that has accountability for the case management, medical review, utilization review, quality management and/or health education team and programs. Monitors and evaluates the operational performance of overall departmental direction, leveraging analytics, regional market trends and utilization trends of members to set future direction and refine current state. Develops long term plans that will improve utilization, quality and clinical outcomes based upon population health or data analytics, governing agencies, organization’s mission, vision, and direction. The incumbent is responsible for the leadership, performance management for supervisory staff as well as company and department objectives, supporting providers in a variety of health care settings to appropriately identify members with chronic conditions and/or gaps in care that can be positively impacted related to quality and care costs. (note that health care settings could include, but not limited to, working in a physician’s office, visiting physician practices on a routine basis, working within a hospital setting and/or assessing and coordinating member’s care within the member’s home, working within an ancillary healthcare provider setting such as, but not limited to, behaviorist, developmentalist, or working within a community-based support setting such as, but not limited to, provider of tangible aide, or work program ).
- Perform management responsibilities including hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity.
- Plan, organize, staff, direct and control the day-to-day operations of the department; develops and implements policies and programs as necessary; may have budgetary responsibility and authority.
- Assist in the development of goal-setting and establishing future direction of the operations of a combined case management/utilization management team and assists with operations planning and efficiency.
- Ensure overall compliance with applicable business process requirements, regulatory requirements and accreditation standards that support all lines of business.
- Serve as key resource to both supervisory staff and external sources on complex issues, departmental direction and future planning.
- Develop proposals to improve overall efficiency and managed care experience, utilization, quality and clinical outcomes.
- Collaborate with supervisor staff and providers for insights to inform future direction and refinement of overall operations.
- Collaborate with the appropriate cross- functional leadership and external entities to formulate new, innovative ideas to improve departmental performance, reduce costs while enhancing member experience.
- Other duties as assigned or requested.
- Bachelor's Degree in Nursing (BSN)
- 4 years in any combination of Clinical, Case Management and/or Disease/Condition Management, Provider Operations and/or Health Insurance
- 4 years in Management
- 5 years in any combination of Clinical, Utilization/Case Management and/or Disease/Condition Management, Provider Operations and/or Health Insurance
- Experience with an ACO model, and 2703 Health Home
LICENSES AND CERTIFICATIONS
- Current Arkansas RN license or current Social Work license
- Clearances as required by specific practice or hospital, as applicable
- Current Arkansas resident
- Certification in Case Management (CCM)
- Proficiency in MS Excel and enhanced data and statistical analysis skills
- Excellent interpersonal/ consensus building skills as well as the ability to work with a variety of internal and external colleagues from all levels of an organization
- Broad knowledge of the health care delivery system including an understanding of health care costs drivers
- Excellent verbal and written communication skills including individual and/or group education/training
- Experience working with the healthcare needs of diverse populations and understanding the importance of cultural competency in addressing targeted populations.
- Self-directed; self-starter; ability to work successfully with indirect supervision and moderate autonomy
- Excellent organizational, time management and project management skills
- Ability to work in a fast paced, high visibility, high performing team environment that requires flexibility
- Ability to travel locally and work flexible hours in a practice or facility-based settings
- Ability to communicate effectively in more than one language, preferred
- Experience working directly with physicians and other healthcare providers, as well as providers of tangible aide or other support services such as, but not limited to: school-based services, vocational services, job services
- Experience meeting with members in multiple settings including but not limited to: the member’s home or identified place of residence, the office of a healthcare provider or provider of tangible aide, a hospital or other level of care to support care plan coordination, discharge planning, and/or transition between levels of care
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