Direcor of Case Management

POSITION SUMMARY

 

Under limited supervision, leads and directs activities to ensure case management programs are operational and functioning effectively in order to meet the needs of Bravo Health members. Subject matter expert for CMS compliance issues and other efforts including Case Management, Disease Management, Chronic Care Improvement Program, and Special Needs Plan. Focused on implementing initiatives to improve the health and quality of life of members. Design programs to decrease admission rates and improve disease management activities. Participates in and contributes to the development of annual work plans and strategies for Health Services. Writes policies and procedures, prepares for accreditation reviews and audits and works to ensure that corrective actions are remediated efficiently and effectively.  Ensures that quality healthcare services are available to Bravo Health members in a medically appropriate and cost-effective manner.

 ESSENTIAL DUTIES AND RESPONSIBILITES

 

·        Responsible for development of intensive case management program focused on reducing admission rates associated with patients in the chronic at risk for frequent admissions population.

·        Develop and implement Structure and Process (S&P) measures associated with the Special Needs Plan (SNP).

·        Provide strategic direction to improve the healthcare outcomes of the large proportion of dual-eligible Bravo members.

·        Oversee disease management activities and programs.

·        Responsible for case management programs, policies, and initiatives as required by all regulatory bodies.

·        Assist in the development of the yearly UM work plan for Health Services.

·        Recruit key management positions and develop staff retention program.

·        Work with regulatory bodies to develop criteria, guidelines, and performance outcomes by writing policies and procedures that document the effectiveness of case management programs.

·        Provide oversight to regulatory manager to ensure compliance standards are met or exceeded.

·        Participate in key internal and external work groups.

·        Work closely with the Quality Improvement department in preparation for regulatory audits.

·        Partner with network providers to establish programs to improve quality outcomes through increased member focus and monitoring.

 

MINIMUM QUALIFICATIONS

 

·        Bachelor of Science in Nursing.

·        Valid nursing license in the states of Pennsylvania, Maryland or Texas and the ability to obtain license in all three states.

·        5-10 years progressive experience in managed care or similar setting with emphasis on Case Management, regulatory or government agency programs, and quality improvement initiatives.

·        MBA or equivalent Master’s Degree preferred.

 

KNOWLEDGE, SKILLS, AND ABILITIES

·        Knowledge of Medicare/Medicaid rules and regulations.

·        Demonstrable experience leading change and achieving results in the managed care health services arena.

·        Skill in thinking strategically and critically and in managing multiple priorities simultaneously.

·        Skill and experience in developing metrics and monitoring and analyzing departmental performance statistics.

·        Ability to evaluate and measure case management outcomes and performance in a quantitative manner.

·        Ability to analyze and present quantitative information in graphical format.

·        Strong knowledge of Microsoft Excel.

·        Comfortable working in unstructured and highly fluid environment requiring extensive hands-on participation.

·        Experience in developing and implementing policies and procedures.

·        Skill and demonstrable experience in managing and motivating staff to perform effectively.

·        Skill and ability to research and interpret policies and procedures and to communicate effectively both orally and in written form with a variety of internal and external constituents, agencies, and groups.

·        Skill and demonstrable experience in assessing staff training needs and in developing and delivering effective baseline and ongoing training for staff.