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Manager of Operations for Care Management Initiatives
2 months ago
Manager of Operations for Care Management Initiatives
WellSense Health Plan is a nonprofit health insurance organization dedicated to serving members across various states through Medicare, Individual and Family, and Medicaid programs.
Established as a health plan provider, we offer services tailored to meet the diverse needs of our members.
Joining WellSense Health Plan presents an opportunity to be part of a dynamic organization with a rich history of delivering effective health insurance solutions.
Position Overview:
Reporting to the Care Management Operations Manager, the Operations Manager is tasked with overseeing and analyzing our care management initiatives, ensuring compliance, program development, evaluation, and performance assessment.
This role encompasses the management and accountability for the daily non-clinical operations of these initiatives and serves as the expert in program operations.
Our Commitment to You:
Remote work options
Competitive compensation packages
Comprehensive benefits
Key Responsibilities:
Ensure adherence to contractual and regulatory standards while effectively documenting the necessary components for compliance with regulatory and accreditation requirements.
Analyze the implications of accreditation and regulatory modifications, providing recommendations for programmatic adjustments to maintain compliance.
Direct and oversee all non-clinical operational and management functions of the Care Management teams, including the creation and implementation of effective metrics to monitor productivity and compliance.
Facilitate team meetings and additional departmental gatherings as needed.
Identify opportunities for enhancing existing operational policies and procedures, developing new protocols as required.
Guide internal departments and Care Managers on decisions impacting members regarding benefits, service payments, and other non-clinical matters.
Collaborate with clinical departments on issues necessitating clinical cooperation and coverage.
In partnership with the Medical Management team, represent the programs and the Director in complex cross-functional teams and projects, acting as the subject matter expert on care management issues.
Timely identification, communication, and escalation of issues are essential. Independently resolve programmatic challenges and implement suitable solutions.
Serve as the subject matter expert for workflows, processes, and initiatives related to care management programs, collaborating with other business areas including IT, Clinical Informatics, and Quality on business requirement development.
May represent the programs in discussions with external auditors and regulators, ensuring compliance and effective program planning.
Conduct annual reviews and updates of non-clinical policies, job aids, and workflows to align with model of care changes and ensure ongoing regulatory compliance.
In conjunction with Medical Management, lead efforts to ensure adherence to NCQA standards and new contractual obligations, identifying improvement opportunities and initiating corrective actions as necessary.
Prepare and deliver updated NCQA training for all Care Management staff at least annually.
Collaborate with Finance to monitor performance metrics.
Develop and oversee the generation of standard reports to evaluate overall department metrics and care management program effectiveness.
Accountable for tracking key performance indicators related to care management goals and outcomes, implementing operational changes in partnership with care management leaders as needed.
Responsible for notifying leadership promptly if performance metrics fall below expectations, collaborating with leadership to identify improvement opportunities and implement necessary interventions.
Supervision:
Weekly oversight from the Care Management Operations Manager.
Qualifications:
Education:
Bachelor's degree or equivalent experience in a health plan environment is required; a Master's degree in a health-related or public health field is preferred.
Experience:
5+ years in healthcare or managed care settings.
5+ years in project or program management or relevant experience.
Competencies and Skills:
Exceptional written and verbal communication abilities.
Strong organizational skills and attention to detail.
Ability to engage with all organizational levels and external stakeholders.
Proficient in leading cross-functional teams and facilitating meetings.
Demonstrated capacity to work independently and manage multiple complex projects simultaneously.
Proactive, motivated, and a collaborative team player.
Ability to adapt quickly to changing priorities.
Strong analytical, critical thinking, and problem-solving skills.
Proficient in MS Office tools including Word, Excel, PowerPoint, Visio, and MS Project.
Ability to manage competing priorities and stakeholders with differing objectives.
Effective in forming partnerships with other departments to achieve project goals.
Working Conditions:
Work is typically performed in an office environment, with options for remote work.
Fast-paced work setting.
Regular and reliable attendance is essential for this role.
