Clinical Program Manager

20 hours ago


Orange, California, United States Prospect Medical Holdings Full time
Job Title:

Clinical Program Manager - Outpatient Case Management

Job Summary:

The Clinical Program Manager - Outpatient Case Management will be responsible for the daily oversight and management of Prospect Medical Systems' Outpatient Case Management department. This includes managing outpatient CM areas, organizing and executing Outpatient CM activities, and ensuring compliance with all external and internal CM requirements.

Key Responsibilities:
  • Manage outpatient CM areas, including organizing and executing Outpatient CM activities aimed at improving delivery of clinical services needs within Prospect Medical Systems.
  • Continuously evaluate data outcomes, identifying alternatives, preventing unnecessary costs and services while ensuring quality care and patient satisfaction.
  • Perform supervisory audits as necessary to ensure compliance with all external and internal CM requirements and ensure the quality of CM provided to members/beneficiaries.
  • Assist with the development and implementation of departmental policies and procedures.
  • Hire, train, coach, counsel, and evaluate the performance of direct reports.
  • Improve the effectiveness and efficiency of case management staff through process improvements.
  • Provide leadership and supervision to case managers, social workers, and case management coordinators.
  • Oversee all Health Plan reporting completions and submissions in a timely manner.
  • Participate in onsite and/or web-based health plan audits as scheduled.
  • Respond to Corrective Action Plan (CAP) as issued by contracted health plans.
  • Collaborate with the Internal Audit and Compliance Team to ensure CM case audit thresholds are met and compliance issues are identified for prompt resolution.
  • Participate in interdepartmental and cross-functional meetings as needed.
  • Serve as a liaison and resource between case management and other departments across the organization.
Qualifications:
  • Three plus (3+) years of case management experience in managed care required.
  • Three plus (3+) years demonstrated leadership and team management/development skills preferred.
  • Experience in health plan audits and compliance is a plus.
  • Graduate of accredited nursing program.
  • LVN/RN unrestricted active license required.


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