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Reporting to Manager of SNP Care Management Operations, the SNP Lead Care Manager will be an integral member of the health plan's medical management team. This position is responsible for providing coordination of care to SNP members, including establishing and maintaining a care plan, coordinating care with ICT members and coordinating care during transitions of care. 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. Three (3) years of healthcare clinical experience.
2. One (1) years Care Management, Case Management or Population Health experience.
PREFERRED QUALIFICATIONS:
EDUCATION, CERTIFICATION, AND/OR LICENSURE:
1. Bachelor's Degree in Nursing OR Associate of Science in Nursing Degree (ASN) or Diploma.
EXPERIENCE:
1. Management of Medicare and/or Medicaid and/ or SNP populations.
2. One (1) year SNP 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. Conduct intake assessments with members and families.
3. Develops individualized care plans that account for physical, financial, and other constraints.
4. Acts as a liaison for the Interdisciplinary Care Team (ICT) in conjunction with the PCP and beneficiary/caregiver.
5. Provide resources and benefits available to assist and educate the beneficiary/ caregiver to develop and/or improve self-management skills and achieve quality of life.
6. Collaborate with other CM team members to support the beneficiary through TOC events.
7. Act as the primary contact for the member/caregiver, PCP, specialists and ancillaries related to the Care Management Program.
8. Utilize NCQA standards in auditing processes of member records as part of care management oversight processes.
9. Review and Evaluate Health Risk Assessment (HRA) data to help drive development of programs and services geared toward member needs.
10. Manage and triage member self-referrals to care management programs.
11. Participate in case management and quality committees.
12. Assist in reviewing and updating activities and resources to address member needs.
13. May review medical records and other documentation to ensure quality care.
14. Investigating potential quality of care issues that may affect the quality or safety of the health of members.
15. Assist in quarterly reporting of delegated case management processes to meet accreditation standards.
16. Assist members in understanding their available medical benefits and connecting them with in network providers and community resources.
17. Identify barriers preventing the member from meeting maximum quality of life.
18. Perform virtual face to face visits when needed to assist members in coordination of care needs.
19. Assist in ensuring compliance with CMS SNP Model of Care (MOC) expectations, NCQA standards, and Medicare Advantage regulatory requirements.
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.
SKILLS AND ABILITIES:
1. Demonstrated knowledge of CMS regulatory and contractual documents; knowledge of Medicare Advantage, NCQA accreditation standards, disease management, utilization management, care management and discharge planning.
2. Excellent written and oral communication.
3. Problem solving capabilities to drive improved efficiencies and customer satisfaction.
4. Attention to detail.
5. Proficiency with Microsoft Office products.
6. Ability to work under stressful working conditions.
7. 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