Senior Care Manager - Peak Health

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Reporting to Manager of Care Management, the Senior Care Manager will be an integral member of the health plan’s medical management team. This position is responsible for onboarding new employees and mentoring members of the care management team including providing education, performing documentation audits, and building clinical team members expertise through direct feedback and real-time coaching. This position is committed to the constant pursuit of excellence in improving the health status of our members and community. This team member will have high organizational visibility and responsibility in ensuring overall excellence in all areas of care management.

MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Current Registered Nurse license issued by the state in which services will be provided or current multi-state Registered Nurse license through the enhanced Nurse Licensure Compact (eNLC).

EXPERIENCE:

1. Five (5) years of healthcare clinical experience

PREFERRED QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Bachelor's Degree in Nursing OR Associate of Science in Nursing Degree (ASN); Currently enrolled in a BSN program and BSN completion within three (3) years of hire

EXPERIENCE:

1. Management of Medicare and/or Medicaid populations

2. Five (5) years Care Management experience

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position.  They are not intended to be constructed as an all-inclusive list of all responsibilities and duties.  Other duties may be assigned.

1. Participate in activities related to care management program build, implementation, oversight, and delegation.

2. Utilizing NCQA documentation standards, performs audits of member records as part of care management oversight processes.

3. Assists in the development and implementation of policies and procedures related to the Care Management process

4. Assists with monitoring performance standards, productivity and ensuring staff coverage to meet the needs of the department

5. Formulates, implements and evaluates educational strategies for staff

6. Maintains a working knowledge of the requirements of regulatory and compliance entities

7. Mentors new Care Managers and assists with training

8. Provides support and coaching to Care Managers and other clinical team members

9. Perform data collection and analysis of trends to determine areas of opportunity and strategies for better practices for the Care Manager team

10. Takes escalated calls or fills-in for the Care Manager team during high-peak periods

11. Assist in quarterly reporting of delegated case management processes to meet accreditation standards

12. Assist in submission of required documents/policies during application process to accrediting body

13. Provides clinical, procedural or interpretational assistance

14. Ability to present complex ideas and data to a wide variety of stakeholders from frontline employees to executive c-suite.

15. Establishes and maintains cooperative and positive working relationships with key stakeholders across the organization.

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Ability to stand and walk short distances for eight or more hours.

2. Frequent bending, stooping, or stretching.

3. Ability to lift 30 pounds and push 50 pounds.

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Standard office environment

2. Some travel may be required to offsite meetings.

SKILLS AND ABILITIES:

Demonstrated knowledge of CMS regulatory and contractual documents; knowledge of Medicare Advantage, NCQA accreditation standards, disease management, utilization management, care management and discharge planning.

Excellent written and oral communication

Problem solving capabilities to drive improved efficiencies and customer satisfaction

Attention to detail

Proficiency with Microsoft Office products.

Ability to work under stressful working conditions.

Meeting defined deadlines and deliverables is an imperative skill for this role.

Additional Job Description:

Scheduled Weekly Hours:

40

Shift:

Exempt/Non-Exempt:

United States of America (Exempt)

Company:

PHH Peak Health Holdings

Cost Center:

2403 PHH Medical Management