Risk Management Team Lead Jobs (NOW HIRING)

Base pay is influenced by several factors including a candidate’s qualifications, relevant experience, and anticipated contributions to meet the needs of the business, along with internal pay equity and external market driven rates. The salary range displayed has not been adjusted for geographical location. This range has been created in good faith based on information known to Capital Blue Cross at the time of posting and may be modified in the future. Capital Blue Cross offers a comprehensive benefits packaging including Medical, Dental & Vision coverage, a Retirement Plan, generous time off including Paid Time Off, Holidays, and Volunteer time off, an Incentive Plan, Tuition Reimbursement, and more. 

At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it’s why our employees consistently vote us one of the “Best Places to Work in PA.”

The Care Management Team Lead oversees the daily operations of the Care Management unit: Case Management, Disease Management, Social Work, and specialty programs and services. The Care Management Team Lead ensures and evaluates care management process implementation, evaluation of productivity and outcome metrics, policy and regulatory compliance, and identifies and communicates areas for process improvement. The Care Management Team Lead is responsible for the direct supervision of the unit’s staff, professional development, and performance improvement.

• Facilitates ongoing staff development. Acts as mentor to the care management staff by providing regular feedback regarding their performance identifying strengths and plans for areas of improvement.
• Demonstrates ongoing oversight of care management activities. Evaluates performance metrics including but not limited to utilization trends, engagement rates, staff productivity, patient satisfaction and other department/organizational metrics. Identifies, develops and/or implements plans at the department, program, and/or member level to achieve results.
• Supports care management staff in care planning and troubleshooting complex problems and Members’ needs, resource constraints, provider issues etc. Promotes interdisciplinary team collaboration and communicates needs, issues, resolution with leadership.
• Performs quarterly audits (phone calls and documentation review) to ensure accreditation and regulatory compliance, department performance standards met. Works with leadership and staff to resolve identified issues. Completes additional audits as necessary to evaluate and mentor staff.
• Lead case review to facilitate co-management and multidisciplinary communication.
• Identifies and reports quality of care issues in accordance with established departmental policies and procedures. Maintains member confidentiality at all times.
• Attends company and departmental meetings and training sessions as required.

Skills:

• Strong team skills with the ability to work and interact with management level staff both within and outside of Clinical Management.
• Excellent critical thinking skills, forward thinking and problem solving skills. Able to identify potential solutions to existing problems and seek input when necessary.
• Ability to multi-task and handle competing priorities. Excellent time management and organizational skills.
• Superior clinical process, critical thinking, and problem solving skills; and ability to handle critical situations.
• Excellent written, oral communication, listening, and organizational skills.
• Ability to use computer system while conversing telephonically
• Able to demonstrate strong customer service skills, including tact and diplomacy, both in person and telephonically when communicating with internal and external customers
• Ability to appropriately prioritize workload and assignments and perform accurate, detailed and timely completion of assigned duties.
• Ability to work autonomously and as part of an interdisciplinary team
• Demonstrates sound judgment that affirms the rights and responsibilities of Member’s, families, health care professionals and health care organizations.
• Ability to operate a personal computer (PC), including proficiency in Microsoft Office Products.

Knowledge:

• Keeps abreast of developing trends, knowledge, and skills. Assesses and analyzes current process and makes recommendations to Director and other management as appropriate.
• Demonstrates core leadership and management skills; seeks opportunities for feedback and leadership development.
• Knowledge of NCQA standards for Population Health Management for health plan accreditation, DMAA standards for disease management and CMSA Standards of Practice for Case Management, Act 68, NCQA, CMS and ERISA.
• Knowledge of clinical and managed care principles and operations.
• Knowledge of current and emerging medical treatment modalities and best practice guidelines with the ability to analyze and interpret medical and benefit coverage interrelationships.
• Knowledge of adult learning principles, motivational interviewing and intrinsic coaching techniques.

Experience:

• At least five (5) years’ experience as a care manager: Case Manager, Disease Manager, Social Worker or equivalent experience. Supervisory/leadership experience preferred.

Education and Certifications:

• Registered Nurse with a bachelor’s degree (or higher) in a health-related field OR
• Master’s in Social Work degree.
• Active licensure in home state; additional state licensure as needed to meet customer needs.
• Case Management Certification preferred. Subsequent to completing one (1) year in the position, the incumbent must obtain national certification as a case manager.
• Possession of a valid driver’s license and the ability to travel to provider, facility, employer group and/or member locations using own vehicle, if appropriate.

Work Environment:

• Hours vary depending on department and customer needs. Primarily remote work from home with expected travel to office for meetings as needed.

Physical Demands:

• Sedentary work involving significant periods of sitting, talking, listening, typing and performing repetitive motions. Work requires visual acuity to perform close inspection of written and computer generated documents as well as a PC monitor.

Other:

• Key Interfaces:
• Care Management staff, Clinical leadership, internal and external customers including providers and physicians.
• Number of direct and indirect reports:
• Approximately 8-20FTE
• Other job responsibilities as assigned to meet emerging business needs.