Job Summary:
The Manager, Case Management - Integrated Care is responsible for overseeing the Integrated Care Duals Product Teams in coordinating the care, service and health benefits for selected member populations.
Essential Functions:
Monitors and promotes safe and effective utilization of healthcare resources through clinical variance and benefits management
Actively manages the performance of the Integrated Care Management Liaisons and internal/external Care Management teams to ensure safe and effective service delivery, quality outcomes, and compliance with all state and accreditation requirements
Assist in verifying eligibility, previous enrollment history, demographics and current health status of each member as appropriate
Audit and review documentation gathered by internal staff and external partners to ensure thoroughness, accuracy and care management competency
Contribute to the ongoing review of Member care plans, defining specific issues, goals and interventions as appropriate
Responsible for ensuring that member/CM caseload ratios are kept at optimal levels
Ensures that CM teams monitor and evaluate care plan effectiveness on an ongoing basis through member, family, provider, and stakeholder contact
May assist Member liaisons in the facilitation and coordination of services based upon the care treatment plan developed in collaboration with all stakeholders
Working with peer Managers and Director, responsible for overall day-to-day Care Center operations, team coordination, and member outcomes, including, new staff orientation and scheduling, training, in-servicing, quality and performance improvement, regulatory and contractual compliance
Oversees effective care planning and implementation meeting member needs
Oversees the coordination of services with community partners to maximize utilization of appropriate community resources and supports, and assure effective and appropriate transitions between settings of care
Works with Incident Management staff in the review and investigation of member incidents and/or issues related to member health and safety
Works with Community Partners, Provider Relations and Network Management staff in the ongoing monitoring of quality issues for network providers
Monitoring of scheduling/work allocation and productivity
Provides quality monitoring and conducts regularly scheduled one-on-one meetings with all team members
Works with corporate staff in the follow up and review of member complaints and grievances
Monitor and analyze Integrated Care Management data and reporting
Assures overall compliance with the Integrated Care product model of care
Oversee and/or maintain current and accurate documentation of contacts, care treatment plans, case notes, referrals, and assessments in Care Management electronic record and within protocols and guidelines of the Care Management program
Actively oversee the performance of the Integrated Care Management teams to ensure all state and accreditation requirements are achieved
Review and update all Care Management policies and Standard Operating Procedures
May participate in meetings with providers to inform them of Care Management services and benefits available to members
Serve as interdepartmental liaison and network with other departments to gather/share information about issues related to the Care Management process
May assist in education of member/caregiver regarding healthcare access and benefits, and provide member/caregiver with health education and wellness materials
Precept and/or mentor new staff
Provide ongoing training, mentoring, coaching and disciplinary action as needed
Participate in the hiring process of new Integrated Care Management personnel
Provide guidance/instruction for Integrated Care Team Leads and other staff via formal and informal meetings
Regular travel to conduct member visits, provider visits and community based visits as needed to ensure effective administration of the program
Perform any other job duties…