Manager of Case Management

Job description:

JOB TITLE: Clinical Manager of Care Management

COMPANY: IHP

REPORTS TO: Director of Clinical Strategy

DIRECT REPORTS: None

STATUS: Exempt / FULL-TIME

OUTSIDE TRAVEL: 25%

WORK SCHEDULE: 7-7/M-F (Flexible 9/80 schedule)

WORK CONDITIONS: Remote

This job description is intended to be a general statement about this job and is not to be considered a detailed assignment. It may be modified at any time, with or without advance notice, to meet the needs of the organization.

Job Summary

Under the direction of the Medical Director and Director of Clinical Strategy, the position is responsible for leading and coordinating care management services across the network that include care coordination and activities that promotes the quality, cost, and experience of care. The position is responsible for developing a vision and executable plan to attain high quality performance for the clinically integrated network through partnership with the FQHC members, health plans and vendor partners and must understand care management principles, quality management and healthcare reimbursement models.

Essential Job Functions

• Hire and manage a team of care manager (RNs and LVNs) plus health care liaisons
• Build a Care Management program strategically aligned with a hybrid network model to ensure success in risk-based contracts.
• Partner with the PHIT and IT vendor teams to develop innovative care management methods utilizing technology, tools, and teams.
• Build the Arcadia Care Management module to meet the needs of the FQHC based network.
• Become a clinical resource to member health centers for care management best practices.
• Identify at risk populations and provide clinical coordination necessary to improve quality of care and control cost for patients attributed to IHP's network.
• Coordinate care between health plans and health centers to ensure there is a cohesive plan to help patients achieve optimal health outcomes.
• Review payer and Arcadia quality performance reports to identify the quality metrics that are performing below performance thresholds and develop and implement clinical action plans to address gaps in care, access, and/or quality outcome issues.
• Work with clinicians and key stakeholders to develop, maintain, and monitor the implementation of the care management strategies that support value-based contracts.
• Apply and teach clinical techniques for quality improvement, outcomes measurement and statistical analysis to advance quality and improve health equity of communities.
• Conducts comprehensive assessments to address the whole-person client needs.
• Create care plans for clients with short and long-term goals and the steps to achieve those goals.
• Facilitate and coordinate care needs for identified clients that promote quality and controls cost.
• Evaluate client's progress, making adjustments to plan of care as needed to improve outcomes.
• Prepare case related reports that include clinical summary, barriers to goals, outcomes, and prognosis.
• Follow up on client referrals to ensure that clients can access and receive necessary services in a timely manner.
• Coordinate and provide care that is safe, timely, effective, efficient, equitable, and client centered.

Utilization Management

• Partner with the Management Services Organization (MSO), as the primary owner of UM, to perform utilization management reviews for risk-based contract performance by health center and provider.
• Work with the health centers to review utilization patterns and identify improvement plans to improve areas of concern from the UM reviews.
• Partner with payers to design UM processes to improve facility-based events (ED/IP) to ensure proper utilization and outcomes.
• Serve as a clinical resource to member health centers for care management best practices.

Coding & Documentation Integrity

• Provide clinical guidance on coding or documentation audits performed by the Coding & Documentation Integrity Team.
• Utilize CDI audit findings to educate teams on clinical performance and improvement efforts.

Other

• Develop team members and create tools to ensure strong teams and processes are in place for success.
• Meet annual goals outlined by leadership that align with the network strategic plan.
• Establish and maintain collaborative working relationships with community resources.
• Actively participate in staff meetings and training.
• Perform other duties as assigned.

Qualifications

Skills

• Must have strong interpersonal skills to work effectively internally and externally and across all levels in an organization.
• Working knowledge of regional health disparities and social determinants of health.
• Working knowledge of Medi-Cal regulations and a variety of rigorous process improvement and quality outcome measurement methodologies, such as, Rapid Cycle Testing, PDSA, FMEA, Healthy People 2010/2020, HEDIS, P4P.
• Working knowledge of relevant computer systems and software.
• Must have excellent written and verbal communication skills.

Education/Experience

• RN license required.
• CCMC, or equivalent, certification preferred.
• Must have 5 years of clinical experience: 6+ years preferred.
• Must possess valid driver's license, insurance, and own transportation for use in work, and be flexible with working some evenings and weekends within a 40-hour workweek.
• Preferred to reside in San Diego County.
• Must be willing to travel, as needed.

Physical Requirements

• Ability to sit or stand for long periods of time
• Ability to reach, bend and stoop
• Physical ability to lift and carry up to 20 lbs.

HIPAA/Compliance

• Maintain privacy of all patients, employee and volunteer information and access such information only on as need to know basis for business purposes.
• Comply with all regulations regarding corporate integrity and security obligations. Report Unethical, fraudulent, or unlawful behavior or activity.
• Upon hire and annually attend HCP's HIPAA training and sign HCP's Confidentiality & Non-Disclosure Agreement and HIPAA Privacy Acknowledgment
• Upon hire and annually read and acknowledge understanding of HCP's HIPAA Security Policies and Procedures
• Adhere to HCP's HIPAA Security Policies and Procedures and report all security incidents to HCP's Privacy & Security Officer

"
We are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity or expression, pregnancy, age, national origin, disability status, genetic information, protected veteran status, or any other characteristic protected by law".

The pay range for California residents for this position is $104,000-$135,000, however, the actual base pay offered may vary depending on skills, experience, job- related knowledge and location.