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Director of Care Management, CRC, CT
We are hospitals and affiliated medical groups, working closely together for the benefit of every person who comes to us for care. We build comprehensive networks of quality healthcare services that are designed to offer our patients highly coordinated, personalized care and help them live healthier lives. Through collaboration, we strive to provide all of our patients and medical group members with the quality, affordable healthcare they need and deserve.
The Director of Care Management is responsible for the management and oversight of ambulatory and practice-based Care Management, Complex Care and Transition of Care programs for any attributed or eligible patients in the market. Additionally there are key partnerships and workflows that must be built and maintained between the IPA, Hospitals and Post-Acute Care suppliers and providers to include: Disease Management programs (HF, COPD, Diabetes, etc.), Complex Care Management, PCMH Practice Care Management, Palliative Program, In-Home Care Management, and Behavioral Health Integration based on health plan/payor contracts. Ensures all Care Management Programs meet State, Federal and appropriate NCQA standards and meet/exceed care management performance levels for all applicable attributed or eligible patients.
The Director of Care Management will manage teams responsible for assisting patients in navigating the health care system and ensuring access to evidence based care. Ensures Evidence Based Care is documented and executed via the CRC Population Management platform whenever possible and that these efforts reflect CRC best practices whenever applicable. Develop and implement Key Performance Indicators for Care Manager productivity and performance as needed to augment the Payer contractual requirements.Job Responsibilities/Duties
- Develop and implement integrated care management programs that improve, facilitate and streamline the care delivery process and the patient and provider experience while dramatically improving measurable quality, cost and experience through the following activities:
- Develop and promote a fully integrated approach to care management, transitions of care and complex care management while looking for clinically appropriate opportunities to reduce overall costs.
- Ensure that any delegated care management programs are adherent to NCQA Complex Care Management, Disease Management Standards
- In collaboration with internal and external stakeholders build sustainable, integrated programs and activities for Post Acute, Next Site of Care optimization.
- Oversee the continued development, implementation, integration and organization of all case and disease management programs and transition all documentation, workflow, and reporting capabilities to the CRC Population Management platform whenever possible.
- Identify and evaluate potential new programs, partnerships and services to improve quality of care, enhance the member experience and reflect cost effectiveness.
- Ensures that all care management and care coordination documentation meet NCQA and Complex/Disease Management standards.
- Manage team to develop and implement metric driven care management programs that meet or exceed regulatory and health plan requirements, improving quality, cost and experience results through the following activities:
- Conduct evaluations of care and disease management programs to determine effectiveness and need to modify, enhance or eliminate.
- Complete audit and oversight of the individual care and disease managers to ensure adherence to NCQA standards, care management protocols and effectiveness. Provide coaching and training to staff.
- Monitor Daily Key Performance Indicators including: readmissions, ED visits, SNF admissions, care management reach and patient engagement rates to identify trends and recommend course correction.
- Prepare summarized reporting and any accompanying program recommendations for senior leadership.
- Ensure compliance with all applicable regulatory and accreditation guidelines such as NCQA, CMS, State Department of Health, etc.
- Complete all supervisory administrative duties (timecards, time off, performance management issues) in a timely and professional manner.
- Communicate with, manage and lead a remote team.
- Support the development, engagement and alignment of health system and CRC clinical and operational staff to meet targeted clinical and quality outcomes though the following activities:
- Work with other departments to develop strategies to improve commercial HEDIS measures and CMS Clinical STAR Measures.
- Attend Health Plan and Hospital JOC's when requested and ensure action items are followed up and resolved.
- Attend and participate in operational or interdepartmental meetings as requested.
- Ensure that Policies and Procedures reflect current processes and workflows. Develop additional policy and procedures as required for departmental improvements.
- Recognize market and skill set differences between the East and West Connecticut Markets, while striving for consistency whenever possible.
- Maintaining relationships in both Connecticut markets will require some level of travel between the two markets.
- Complete special projects when required.
Minimum Education: Registered Nurse (RN). Registered Nurse, licensed in CT.
Minimum Experience: Minimum five (5) years' experience in managed care, health plan or IPA arenas. Experience should include: Utilization Management, Quality Improvement, inpatient quality improvement programs, case management programs, health plan incentive programs including P4P/HCC/STAR/HEDIS. Experienced with health plan guidelines/criteria/CMS/NCQA. Strong clinical background in acute and chronic care management. Proven success in improving key performance metrics. Strong independent decision-making and analytical skills. Extensive knowledge of state and federal laws and regulations governing medical agencies. Extensive knowledge of Medicare. Strong organizational skills. Strong problem-solving skills. Ability to work effectively under pressure by prioritizing work activities. Maintains member confidence and protects operations by keeping claim information confidential in compliance with HIPAA requirements. Strong computer skills including the use of Population Management workflow and reporting, as well as Word, Excel, and Power Point.
Req. Certification/Licensure: Registered Nurse, licensed in CT.Employee Value Proposition
Prospect Medical Holdings, Inc., is guided by a diverse and highly experienced leadership core. This group maintains the vision that has made Prospect a needed difference-maker in the lives of so many patients today, and many executives contribute to our continued efforts. As a member of our highly effective team of professionals you will receive:
- Company 401K
- Medical, dental, vision insurance
- Paid time-off
- Life insurance
Prospect Medical Systems has a zero-tolerance policy regarding the use of drugs and alcohol. Our Company is committed to maintaining a productive, drug free workplace that keeps employees and patients safe from harm. For this reason, we require applicants to pass a screening for drug use as a condition of employment. This includes: alcohol, marijuana, cocaine, opiates and methamphetamines.How to Apply
To apply for this role, or search our other openings, please visit http://pmh.com/careers/ and click on a location to begin your journey to a new career with us!
We are an Equal Opportunity/ Affirmative Action Employer and do not discriminate against applicants due to veteran status, disability, race, gender, gender identity, sexual orientation or other protected characteristics. If you need special accommodation for the application process, please contact Human Resources.
EEOC is the Law: https://www1.eeoc.gov/employers/poster.cfm
Keywords: Director, Care Management, Medicare, In-Home-Care, NCQA, CMS, Utilization Management, Quality Improvement, P4P, STAR, HEDIS, HCC, Health Plans, Acute Care, Chronic Care Management, IPA, HIPPA, Population Management, Leadership, training, metrics, reporting.
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