Company :Highmark Wholecare
Job Description :
This job manages and coordinates the supervisory staff that has accountability for the case management, medical review, utilization review, quality management and/or health education team and programs. Monitors and evaluates the operational performance of overall departmental direction, leveraging analytics, regional market trends and utilization trends of members to set future direction and refine current state. Develops longer term plans that will improve utilization, quality and clinical outcomes based on market trends, legislative environment and company’s mission, vision and direction. The incumbent is responsible for the leadership, performance management for supervisory staff as well as company and department objectives, supporting providers in a variety of health care settings to appropriately identify members with chronic conditions and/or gaps in care that can be positively impacted related to quality and care costs. (note that health care settings could include, but not limited to, working in a physician’s office, visiting physician practices on a routine basis, working within a hospital setting and/or assessing and coordinating member’s care within the member’s home).
- Perform management responsibilities including, but not limited to: involved in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity.
- Plan, organize, staff, direct and control the day-to-day operations of the department; develops and implements policies and programs as necessary; may have budgetary responsibility and authority.
- Assist in the development of goal-setting and establishing future direction of the operations of a combined case management/utilization management team and assists with operations planning and efficiency.
- Ensure overall compliance with applicable business process requirements, regulatory requirements and accreditation standards that support all lines of business.
- Serve as key resource to both supervisory staff and external sources on complex issues, departmental direction and future planning.
- Develop proposals to improve overall efficiency and managed care experience, utilization, quality and clinical outcomes.
- Collaborate with supervisor staff and providers for insights to inform future direction and refinement of overall operations.
- Collaborate with the appropriate cross- functional leadership and external entities to formulate new, innovative ideas to improve departmental performance, reduce costs while enhancing member experience.
- Other duties as assigned or requested.
- Current PA RN license and/or additional states as required or current Social Work license
- 4 years of any combination of clinical, case management and/or disease/condition management, provider operations and/or health insurance experience
- 3 years of management experience or leadership in a matrixed environment
- Clearances as required by specific practice or hospital, as applicable
- Certification in Case Management (CCM)
- 2+ years of Utilization Management experience, familiarity with Interqual and/or Milliman criteria
- Proficiency in MS Excel and enhanced data and statistical analysis skills
- Excellent interpersonal/ consensus building skills as well as the ability to work with a variety of internal and external colleagues from all levels of an organization
- Broad knowledge of the health care delivery system including an understanding of health care costs drivers
- Excellent verbal and written communication skills including individual and/or group education/training
- Experience working with the healthcare needs of diverse populations and understanding the importance of cultural competency in addressing targeted populations.
- Self-directed; self-starter; ability to work successfully with indirect supervision and moderate autonomy
- Excellent organizational, time management and project management skills
- Ability to work in a fast paced, high visibility, high performing team environment that requires flexibility
- Ability to travel locally and work flexible hours in a practice or facility-based settings
- Ability to communicate effectively in more than one language, preferred
- Experience working directly with physicians in provider practice settings, members in a home environment or hospital discharge processes.
SCOPE OF RESPONSIBILITY
Does this role supervise/manage other employees?
Is Travel Required?
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, age, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
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