Clinical Program Manager Consultant
4 days ago
The Clinical Program Manager Consultant will play a key role in supporting the overall FEP Care Management team as a subject matter expert, while exemplifying Blue Shield of California's leadership behaviors.
Key Responsibilities- Contribute to the Adoption and Improvement of Care Management Electronic Medical Records
- Participate in go-live testing, which may occur after hours or on weekends, based on the posted monthly release schedule
- Support Operational Targets and Care Management Data Submission
- Prepare and assist with review and submission of Care Management data to the Blue Cross Blue Shield Association (BCBSA)
- Create and Educate the Team on Specifications around HEDIS Measures
- Create and educate the team on specifications around the Healthcare Effectiveness Data and Information Set (HEDIS) measures selected by the Office of Personnel Management (OPM)
- Participate in outreach to members
- Support Team through Consistent and Successful Caseload Management
- Support team through consistent and successful caseload management and workload to achieve team goals, regulatory timelines, and accreditation standards
- Lead Team Huddles and Meetings
- Lead team huddles/meetings to support process changes and encourage collaboration of team members
- Contribute to Departmental Goals and Planning Efforts
- Contribute to the development of goals for the department and planning efforts (budgets, operational plans, etc.)
- Influence the performance of the business unit in achieving Blue Shield of California's objectives
- Responsible for collecting data required for contractual reporting
- Provide Guidance, Coaching, and Training to Other Employees
- Responsible for auditing, providing guidance, coaching, training, and precepting to other employees within the job area
- Collaborate with the training department and operation department to customize training specific to the FEP team
- Prep cases for internal and external audits
- Provide Referrals to Quality Management, Disease Management, and Appeals and Grievance Department
- Provide referrals to Quality Management (QM), Disease Management (DM), and Appeals and Grievance department (AGD)
- Recognize Clients' Rights to Self-Determination
- Recognize the clients' right to self-determination as it relates to the ethical principle of autonomy, including the client/family's right to make informed choices that may not promote the best outcomes, as determined by the healthcare team
- Design Appropriate and Fiscally Responsible Plans of Care
- Design in collaboration with the HEDIS quality team, appropriate and fiscally responsible plans of care with targeted interventions that enhance quality, access, and cost-effective outcomes
- Typically Requires a College Degree or Equivalent Experience
- Typically requires a college degree or equivalent experience and minimum 7 years of prior relevant experience
- Clinical Licensing or Certification Requirements
- Clinical licensing or certification requirements may apply depending upon position. RN, OT, MSW, CPHQ Cert preferred
- Certified Case Manager (CCM) Certification
- Certified Case Manager (CCM) Certification or qualifies to complete certification when eligible based on CCM application requirements preferred
- Demonstrated Ability to Test EMR Systems
- Demonstrated ability to test EMR systems and guide the development of acceptance criteria statements to improve the EMR systems
- Extensive Knowledge of Evidenced-Based Clinical Practice Guidelines
- Extensive knowledge of evidenced-based clinical practice guidelines particularly for chronic conditions
- Working Knowledge of Regulatory and Accreditation Standards
- Working knowledge of regulatory and accreditation standards preferred (NCQA, Case Management Society of America CMSA). Demonstrated and evolving competence in CM functions and standards of practice
- Cultural Awareness and Community Resources
- Possesses cultural awareness to work effectively, respectfully, and sensitively within the client's cultural context
- In-depth understanding of community resources, treatment options, home health, funding sources, and special programs
- Ability to Work Independently
- Ability to work independently with limited oversight
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