Ncqa Jobs in Kentucky (NOW HIRING)

Hours: Shift Start Time: 8 AM Shift End Time: 5 PM AWS Hours Requirement: 8/40 - 8 Hour Shift Additional Shift Information: Weekend Requirements: No Weekends On-Call Required: No

Hourly Pay Range (Minimum - Midpoint - Maximum): $72.290 - $93.280 - $104.470 The stated pay scale reflects the range that Sharp reasonably expects to pay for this position. The actual pay rate and pay grade for this position will be dependent on a variety of factors, including an applicant’s years of experience, unique skills and abilities, education, alignment with similar internal candidates, marketplace factors, other requirements for the position, and employer business practices.

• Supervise the effective implementation of the Ambulatory Case Management (ACM) programs that includes the management of patients in the different areas of the care management spectrum.
• Responsible for operational planning consistent with existing policies and procedures.
• Responsible for supervision of ACM activities to include tracking, trending, and analyzing data, streamlining and improvement of programs, facilitation of provider education, supporting the Medical Directors, and collaborating on interdepartmental activities.
• Develop and implement new programs under the direction of the Manager of Integrated Care Management and Director of Health Services.
• Participates in the development of the annual ACM plans and implementation of corrective action plans related to health plan audits and requirements of National Committee on Quality Assurance (NCQA) and other governing regulatory bodies.
• Collaborates with the Quality, Compliance, and Training Department to effectively integrate and implement processes consistent with health plan, NCQA, DMHC, and CMS requirements.
• Participates in the development and implementation of new programs under the direction of the Manager of Integrated Care Management.

• Bachelor's Degree nursing or health care related field.
• 3 Years experience in a variety of patient care settings such as acute patient care setting, including ICU or Intermediate care units, Medical-Surgical Nursing, and/or Home Health.
• 3 Years in medical management experience, preferably in managed care.
• California Registered Nurse (RN) - CA Board of Registered Nursing -REQUIRED.

• 2 Years leadership experience, preferably in a managed care setting.

• Utilization, Case Management, or Quality Management certification preferred.

• Supervise Ambulatory Case Management staff and operational processes in accordance with NCQA, DMHC, CMS and health plan requirements.
• Oversee the ACM and UM processes of the assigned teams, ensuring staff access to needed information and tools.
• Ensure that tools utilized by ACM teams are up to date and in alignment with regulatory requirements and internal processes.
• Establish and maintain appropriate policies and procedures and training plans to include enforcement of standards for all ACM team activities.
• Coordinate with the Health Services Quality and Compliance department to ensure timely and relevant implementation of training and verify adherence with quality and compliance parameters.
• Implement and maintain the reporting systems for operational and utilization outcome indicators as it relates to the daily ACM operations.
• Implement and maintain regular reporting systems for operation and ambulatory care management outcome indicators.
• Participate in groups in developing and implementing strategic plan to implement organization vision and/or service-culture initiatives.
• Establish specific quality goals, connecting the vision to the necessary actions and long-term strategies.
• Recognize physician needs and concerns and act on opportunities for improvement in conjunction with leadership.
• Collaborate with physicians to address operational issues.
• Promotes positive outcomes in a managed healthcare setting in support of program initiatives.
• Lead team members to facilitate and coordinate quality healthcare services and delivery of goods and services to meet a member's specific healthcare needs in a timely, efficient, and cost effective manner utilizing strong communication, problem solving, and critical thinking skills.
• Direct and collaborate with peers and assists in the case management process as necessary.
• Assists leadership in promoting team performance goals and in monitoring team progress toward accomplishment of departmental goals and initiatives.
• Assists in the ongoing education of providers, physicians and their office staff.
• Implements action plan to improve referral processing under ACM management direction.
• Enforce policies and procedures for all Case Management activities.
• Maintains ongoing analysis of program performance and monitors trends and opportunities for enhancement or expansion of the ACM processes and operations.
• Document ACM processes according to SCMG policies and procedures.
• Collaborate with other disciplines/departments to resolve identified issues with demonstrated improvement in operational flow.
• Facilitate ACM staff and provider collaboration.
• Operationalize and establish efficient ambulatory case management and referral management work flows to ensure timely patient care.
• Bring to attention of the ACM Manager, areas of non-compliance and provide input on actions for improvement.
• Establish and maintain operational documents such as policies and procedures, desktop procedures as well as all other tools that ACM staff utilize to complete case management activities.
• Collaborate with vendors to provide in services as appropriate to provide staff with available services.

• All 90 day and annual performance reviews are completed per Sharp guidelines.
• Provides feedback toward employee performance.
• Facilitates staff's progress toward agreed upon annual performance goals.
• Assure employee files are current and complete, including annual TB testing, Safety Testing, Compliance Training, and annual HIPAA test, etc.
• Manage and assist staff to resolve identified attendance, performance, learning and behavior issues through feedback, counseling, corrective action and goal-setting.
• Hire staffing for the department per department plan.
• Orient/mentor staff into new role resulting in achieved competencies.
• Ensure accuracy with new employee onboarding as it relates to granting systems access, e.g., EPIC, OnBase, health plan websites, EHR, etc.
• Increases retention rate (or reduces turnover) of select group of staff.
• Leads initiative that results in improved teamwork and/or building more effective relationships.
• Decreases occurrences of unsafe work practices and/or worker's injuries.
• Arranges team coverage for ACM teams in the event of staff absence by demonstrating willingness, flexibility, and competence to assign coverage and/or serve as 'float' as needed with thorough understanding of program differences.
• Supports ergonomic improvement initiatives, teaching, and assists with enforcing compliance with measures designed to reduce employee injury.
• Provides training and assistance to staff.
• Mentors others in developing new skills and assuming new responsibilities.
• Staffing schedules are coordinated to assure adequate department coverage.
• Special projects as assigned by Manager, and/or Director.

• Lead groups in developing and implementing strategic plan to implement organization vision and/or service culture initiatives.
• Establish specific quality goals, connecting the vision to the necessary actions and long-term strategies.
• Recognize physician needs and concerns and initiate opportunities for improvement.
• Recognize patient needs and concerns and initiate opportunities for improvement.
• Collaborate with other disciplines/departments to resolve daily operational issues when supervising unit.
• Facilitate staff in prioritizing and problem solving daily operational issues.
• Demonstrate resolution of operational issues with targeted outcomes as negotiated with manager.
• Utilize team-building skills to provide direction, goal setting, and attainment of goals.
• Conduct team meetings to include documentation of agendas and minutes on a consistent schedule.

• Monitor and manage staff deviations from team quality and productivity goals.
• Conduct and report quarterly performance audits and results.
• Establish and maintain staff meetings quarterly to review progress towards meeting quality and productivity goals.

• Plan and develop of operating systems to manage specific SCMG operational and business objectives through the set-up of ACM queues and workflows.
• Participate in the development and implementation of software functionality, upgrades, and system integration.
• Coordinate testing efforts of new and current software functionalities and applications.
• Oversight the process of identifying, reporting, trouble‑shooting, and resolving system problems.
• Analyze the impact of software changes on accuracy and productivity.
• Oversee the ACM ambulatory CM and UM process workflows from an application perspective and staff adherence.

• Maintains competence in all standards of ambulatory case management, referral management and care coordination.
• Keeps current knowledge and understanding of applicable accreditation and regulatory statutes related to health care, managed care, case management practice.
• Serves as a resource and mentor to Health Services teams.
• Attends and actively participates in department/team process/quality improvement activities.

• Maintains ongoing analysis of program performance and monitors trends and opportunities for enhancement or expansion of the program.
• Provides expertise/consultation in developing services/programs, marketing strategies, and business planning.
• Consults/liaisons with other programs and agencies, and consultants as appropriate.
• Collaborates with other disciplines/departments to resolve identified issues.

• Effective interpersonal skills: strong verbal, written and presentation skills.
• Ability to work well with staff for various educational and professional skills backgrounds to achieve common goals.
• Accepts accountability for performance and decisions.
• Thorough computer knowledge, including on-line database and personal computer skills.
• Knowledge of wide variety of local and national resources for use in Care Management process.
• Strong organizational skills with ability to work well under pressure with conflicting priorities.
• Ability to read, speak and hear English clearly.
• Occasional travel between Sharp HealthCare facilities and provider offices; must provide own transportation.
• Demonstrated leadership skills.

Sharp HealthCare is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender, gender identity, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified individual with disability or any other protected class

Sharp HealthCare is a not-for-profit health care system based in San Diego, California, with four acute care hospitals, three specialty hospitals, three medical groups and a health plan. We provide medical services in virtually all fields of medicine, including primary care, heart care, cancer, orthopedics, women’s health, rehabilitation, robotic surgery and bariatric surgery. Sharp sets the community standard for exceptional care. Sharp Grossmont Hospital and Sharp Memorial Hospital have received prestigious Magnet recognition by the American Nurses Credentialing Center for excellence in nursing practices and quality patient care. At the heart of our organization are more than 18,000 affiliated physicians, nurses, staff and volunteers who are on a journey to make health care better for our patients and their families. It’s what we call The Sharp Experience – treating each person with dignity, compassion and respect, and using our clinical excellence and advanced technology to deliver the highest-quality patient care. We are dedicated to transforming the health care experience by making Sharp the best place to work, the best place to practice medicine and the best place to receive care in San Diego.