Manager, Case Management
Under general supervision the Manager is responsible for developing and implementing business plans, and overseeing resources and department operations in a manner that promotes the delivery of quality, cost effective services based on medical necessity, contractual benefits and complies with state and other regulatory requirements. Work is varied and complex, and requires a moderate degree of discretion and independent judgment.
RN Case Managers and Patient Health Navigators.
Resolves, facilitates and monitors resolution of problematic and/or complex issues that arise during care.
Collaborates with agencies and service providers to facilitate case coordination and clinical information sharing.
Reviews concerns identified through the QI process; implements and monitors corrective action plans.
Monitors and analyzes established Case Management program metrics; identifies trends and opportunities for improvements; makes recommendations based on findings.
Develops, implements and maintains department policies and procedures that comply with applicable regulations, guidelines and NCQA standards; reviews and updates as needed.
Assists in development of department objectives, action plans and budgets that align with company-wide and department objectives; monitors progress and implements appropriate interventions based on results.
Works closely with interdepartmental units to establish and improve workflow and processes; identifies issues and opportunities; resolves issues or makes recommendations as required.
Prepares for and participates in regulatory audits; gathers information, maintains required reports, develops and monitors timely and effective corrective actions plans.
Performs routine and ad hoc internal audits to ensure practices adhere to Milliman guidelines, HPSJ criteria and NCQA standards; assists in the development, implementation and monitoring of corrective action plans.
Compiles, develops and submits routine and ad hoc reports, including but not limited to productivity, referral patterns, cost savings, and utilization.
Promotes and maintains, and ensures that direct reports promote and maintain an environment that supports HPSJ’s strategy, vision, mission and values.
Hires, supervises and retains a competent staff.
Strong clinical skills at the RN level as defined in California scope of practice guidelines.
In-depth knowledge of regulatory requirements pertaining to care management for commercial and government sponsored health plans.
In-depth knowledge of medical management information systems, including managed care applications.
In-depth knowledge of the principles and practices of managed care.
In-depth knowledge of audit processes, and the ability to effectively implement and maintain them.
Basic knowledge of NCQA standards.
In-depth knowledge of and proficient skills in Case Management and in-depth knowledge of health care delivery systems as they apply to case management.
Strong knowledge of and ability to identify, implement, monitor and analyze relevant utilization data and implement relevant and effective interventions based on results.
Strong analytical/assessment skills.
Financial acumen: Interprets and applies understanding of key financial indicators to make better business decisions.
Manages complexity: Makes sense of complex, high quantity, and sometimes contradictory information to effectively solve problems.
Decision quality: Makes good and timely decisions that keep the organization moving forward.
Strategic mindset: Sees ahead to future possibilities and translates them into breakthrough strategies.
Drives results: Consistently achieves results, even under tough circumstances.
Resourcefulness: Secures and deploys resources effectively and efficiently; organizes people and resources to solve problems and identify opportunities.
Plans and aligns: Plans and prioritizes work for self and others to meet commitments aligned with organization goals.
Ensures accountability: Holds self and others accountable to meet commitments.
Strong interpersonal skills with the ability to initiate establish and maintain effective working relationships with diverse individuals both inside and outside of HPSJ.
Strong oral and written communication skills with the ability to communicate professionally, effectively and persuasively to diverse individuals and groups inside and outside of HPSJ; includes the ability to effectively explain complex information.
Strong presentation skills, including the ability to tailor presentations to a specific audience, and address and interact with large groups.
Persuades: Uses compelling arguments to gain the support and commitment of others.
Collaborates: Builds partnerships and works collaboratively with others to meet shared objectives.
Situational adaptability: Adapts approach and demeanor in real time to match the shifting demands of different situations.
Being resilient: Rebounds from setbacks and adversity when facing difficult situations.
Strong customer service skills.
Demonstrated ability to articulate and support HPSJ’s vision, mission, values and strategy, integrate into management practices, and foster their manifestation among staff.
Ability to create relevant department objectives, and create, execute and monitor business plans.
Demonstrated ability to develop and manage realistic budgets.
Ability to read, interpret and apply complex clinical information, regulations, guidelines and other materials.
Intermediate mathematics skills, including basic algebra.
Intermediate skills in Word, Excel and Outlook, including the ability to develop spreadsheets, formulas, and create tables and graphs.
Ability to supervise staff in a manner that maximizes employee performance and business results, which includes very strong coaching/counseling skills and ability to function as a mentor.
Ability to speak and be understood in English.
Ability to handle confidential information with appropriate discretion.
Bachelor’s Degree in nursing from an accredited nursing school; and
At least three years as a licensed nurse in a clinical setting; and
At least three years progressively responsible experience with case management, disease management and quality improvement in a managed care setting; and
At least three years supervisory experience.
Master’s Degree in Nursing.
Current unrestricted California RN license.
Valid California driver license and reliable transportation or, the ability to obtain transportation on demand in the counties served by HPSJ if prohibited from getting a driver license due to a medically documented disability.