This job develops and implements the systems and processes to ensure effective services for the Clinical Care and Wellness programs and initiatives. Creates process and system supported designs that ensures market-specific operational, clinical and financial commitments and performance objectives/goals related to Case, Disease Management and Wellness Services can be met. Accountabilities include literature & market research, outcomes and measurement development, intervention and clinical tools design all of which allow for the effective impact on the goals of Clinical Care and Wellness, as well as the effective delivery of proactive, innovative and engaging case management services. This includes ongoing performance evaluation to assure that programs are achieving the outcomes intended and making recommendations for enhancements and new development.
- Develop and implement the clinical programs, systems, and processes needed to ensure effective care management services for Case, Disease Management and Wellness programs for all lines of business. Function well in a matrix environment and collaborate closely with key partners across the enterprise including Clinical Care and Wellness teams, Utilization Management, Workforce Management, Behavioral Health, Pharmacy, Medical Directors, Business Process Engineers, Project Management, Training, IT, Care Delivery Integration, Clinical Product, Analytics, Reporting, Sales, Marketing, and Finance, to design new and enhance existing programs.
- Build clinical content, processes, and leads clinical training development to achieve stated program and department outcomes based on clinical and market research, and evaluation of the population. Partner effectively with Clinical Services Training to relay process changes, develop training content, and implement/deliver training effectively.
- Perform audits of both telephonic interventions and documentation of same to: Ensure that program design is able to be executed effectively to achieve outcomes. Maintain audit readiness and support during customer audits. Facilitate the development of call quality tools and the performance of Inter Rater Reliability sessions across markets and teams to drive the identification and adoption of best practices in engagement, assessment and interventions.
- Use benchmarking through scientific research, networking and literature searches to identify evidence-based best practice, as well as continuously raise the expectations of performance and remain competitive with the product offerings of other health plans and care management vendors. Participates in initiatives to support overarching program deliverables and key outcome metrics to continuously improve member experience and quality, and reduce cost. Facilitate the development of outcomes measurement and reporting, identification and stratification of members, and develops clinical tools for clinicians to deliver programs. Use performance measurement to continuously improve programs.
- Apply project management and program management methodologies and tools in facilitating program initiatives. Participate in strategic initiatives based on the business needs. Leverage knowledge of end to end operations to identify potential business impacts and solicit participation to meet project and business objectives.
- Maintain a working knowledge of project related Medicare regulations to ensure the organization meets compliance standards; NCQA standards to ensure the organization meets accreditation standards; and Commercial account audits to ensure a constant state of audit readiness.
- Other duties as assigned.
- High School Diploma/GED
- Bachelor's Degree in Nursing (Substitutions 6 years of Clinical Nursing Practice)
- Registered Nurse (RN)
- 3 - 5 years in Clinical Services
- 1 - 3 years in Program Management
- 1 - 3 years in Process Design
- 1 - 3 years in the Health Insurance Industry
- Research Experience
- Project Management Experience
- Business Analysis Experience
- General Computer Skills
- Oral & Written Communication Skills
- Master's Degree in Business Administration/Management, Health Administration or Nursing
- Change Management
- Written & Oral Presentation Skills
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
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