Gateway Health Plan
Job Description :
This job manages a team of clinicians charged with promoting quality member outcomes, to optimize member benefits, and to promote effective use of resources. Ensures that care is medically appropriate, high quality, and cost effective. The incumbent is accountable for the oversight; development and maintenance of the department’s case management processes. This may include utilization management, strategic planning, care cost initiatives, system development and quality outcomes. Hires, trains, coaches, counsels, and evaluates performance of direct reports. Ensures compliance with NCQA, URAC, CMS, DOH, and DOL regulations. Works closely with other departments within the corporation to resolve issues and ensure activities coincide with Case Management processes.
Essential Job Functions
- Manage and coordinate all department activities; staff education, policy and procedure development and revision, individual staff audits, oversees overall operations to ensure compliance to standards.
- Ensure appropriate distribution of workload; monitors/tracks staff completion of assigned work.
- Develop and implement modifications needed, to workload plan, to ensure completion and appropriately coach/counsel staff.
- Act as a role model to staff and be able to assist in the day to day activities as needed.
- Provide service support, training and performance metrics/statistics, to the team, in addition to initiating and implementing process improvements.
- Recruit, select, orient, evaluate, counsel, and develop performance improvement plans; promote and terminate per corporate policy; and encourage career development and support of staff.
- Identify and escalate issues appropriately.
- Apply clinical knowledge to work with facilities and providers for care-coordination.
- Plan for and conduct staff meetings that assure corporate and operational communication supported by meeting minutes; and provide an open forum for issues and problem solving.
- Suggest new approaches to complex problems.
- Appropriate targets, measure outcomes and establish plan to negate variances in quality, staff retention, finance and customer satisfaction.
- Provide direct reports with guidance and educational tools in order to ensure compliance with NCQA, URAC, DOH, DOL and CMS.
- Review and provide input into the oversight of policies and procedures to support regulatory requirements related to Case Management.
- Develop and implement appropriate audit requirements in order to ensure compliance with all staff activity related to Case Management.
- Ensure that all staff achieves the minimal qualification of their position through ongoing staff development, counsel and motivate employees, evaluate employees, investigate complaints or performance concerns; implement disciplinary action as needed and in consultation with appropriate authority and Employee Relations.
- Display effective communication skills.
- Maintain consistent and open lines of communication with internal and external customers.
- Communicate changes in processes and programs in order to enhance a share vision and mission.
- Effectively communicate outcomes, data analysis, complex processes and action plans to division/unit staff, corporate partners, and external customers.
- Facilitate and lead informational and educational meetings for internal and external customers.
- Accountable for special projects and enhanced activities within the department.
- Participate in the development and implementation of department/division projects.
- Implement integration processes and planning activities.
- Other duties as assigned or requested.
- Must hold a current and valid license in DE – acceptable licensing includes one of the following:
- Registered Nurse (RN)
- Licensed Clinical Social Worker (LCSW)
- Licensed Social Worker (LSW)
- Licensed Professional Counselor (LPC)
- Other related Clinical License
- High School Diploma or GED
- 5-7 years of clinical experience
- 3-5 years of experience in case management/managed care
- Bachelor’s degree
- One year of supervisory or managerial experience.
- One year in home clinical or case management experience
- Medicare and Medicaid experience
- Managed care experience
- This position allows a work from home arrangement
- Incumbent must reside in Delaware or the greater Philadelphia area
- Incumbent must reside within a commutable distance to the office to accommodate meetings and scheduled training opportunities
Knowledge, Skills & Abilities
- Experience in workforce development and resource management with excellent team building and professional development skills
- Must demonstrate excellent leadership skills and be able to relate to all levels of management and staff as well as individuals external to the corporation.
- Experience in staff/project management
- Strong leadership, collaboration, l and motivational skills
- Ability to multi task and perform in a fast paced, and often intense environment
- Excellent written and verbal communication skills
- Ability to analyze data, measure outcomes and develop action plans
- Be enthusiastic, innovative and flexible.
- Team player that possesses strong analytical and organizational skill
- The ability to prioritize work demands and meet deadlines
- Excellent computer and software knowledge and skills
Referral Award Payout Level: 3
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.
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