Gateway Health Plan
Job Description :
I. GENERAL OVERVIEW:
Develop, implement, and evaluate condition/disease management programs that effectively impact Gateway Health quality and financial goals, including but not limited to: of care, HEDIS, STARS, etc. Programs include member, provider and community components in multi-state environment for both the Medicaid and Medicare lines of business. These programs/interventions are designed to promote early identification, engagement and positive health outcomes for at-risk and high-risk members with chronic health conditions or pregnancy.
Monitor progress and provide reporting on overall performance of the disease management programs and initiatives.
The Disease Management Specialist is expected to be a subject matter adviser and clinical content owner for Gateway Health.
This position will focus on supporting the Women’s Health population. Gateway’s Mom Matters® program is highly regarded as a program that provides our members with the education and support to support a healthy pregnancy outcome. Our Case Managers supporting this program will assist in the design, analysis, and implementation of programs and interventions to improve the health and outcomes for our pregnant members.
II. ESSENTIAL RESPONSIBILITIES:
1. Communicate Effectively:
- Partner/communicate effectively with all Gateway Health constituencies, which includes members, physicians, other health care professionals, internal departments, practitioners and community agencies to identify, educate and promote preventative health care initiatives and condition/disease specific educational programs.
- Collaborate/communicate with Medical Directors and other department managers to assure integration and coordination of the condition/disease management programs with the Case Management, Member Services, Pharmacy, Utilization Management and Quality Improvement departments’ ongoing programs and new initiatives.
- Direct and communicate with external contractors to support compliance and program/initiative roll-outs.
- Communicate with other Health Plans to research competitive practices or collaborate on disease specific health initiatives.
2. Develop Programming :
- Develop programs designed to promote timely and preventive care through targeted member and provider education and outreach. Identify new approaches to resolve complex issues.
3. Monitor Outcomes :
- Monitor progress and provides reporting on overall performance of the disease management programs and related initiatives.
- Monitor outcome and process measures to identify and recommend improvement opportunities for the disease management programs.
- Provide reporting to internal managers/directors and external agencies and assures timely and thorough implementation of disease management interventions.
- Assure that all programs meet state and Federal standards for health education and chronic care management, and recommends options for improving program performance. Maintains all documentation to support outcome evaluation and quality improvement functions.
- Conduct research to identify national best practices that drive and enhance program design, development and implementation.
- Conduct literature searches to identify innovative strategies and techniques aimed at member engagement, program enhancements and culturally relevant teaching materials and care management approaches.
- Maintain a strong working knowledge of clinical standards of care in specialty, and updates internal working documents accordingly.
- Research and identify best practices to assist Gateway Health management in ongoing development and implementation of programs/initiatives designed to address cultural and racial disparities
5. Training and Education:
- Identify educational needs of the staff and develop plan to address those needs.
- Assist in training initiatives for staff in Case Management around condition specific care, new technology and performance measures and outcomes.
- Provide training and education and develops health promotion materials taking into consideration the culturally diverse population that Gateway Health serves.
- Assist with training or education of providers.
- Write articles for the Member and Provider Newsletters.
- Coordinate the production and mailing of disease specific information for members.
6. Workgroup Oversight:
- Convene interdepartmental workgroups which provide input for work plans and projects.
- Maintain required documentation for these workgroups.
- Convene ‘task forces’ to address the need for special interventions which address HEDIS and EPSDT results.
- Report and monitor overall progress of these workgroups.
7. Other duties as assigned or requested.
Education, Licenses/Certifications, and Experience
- Bachelors in Nursing or RN with 4 years experience developing clinical programs, patient education
- Licensed in PA
- Three (3) years experience working in health promotions, healthcare marketing or health education.
- One (1) year experience working closely with local health departments or other community-level healthcare organizations.
- Current Commonwealth of PA license.
- Possess the ability to examine best practices, evaluate data, trends, provider opinions and member awareness for the purpose of trouble shooting and problem solving and making recommendations for improvements
- Experience in the specialty of Maternity/Child health care
- Certification in Public Health, Case Management, or Health Education preferred.
- Masters degree in Nursing or clinical specialty
Knowledge, Skills and Abilities
- Must be able to effectively apply skills to identify, analyze and recommend interventions that will optimize the use of system and/or improve the quality of patient care.
- Must be able to positively represent Gateway Health in meetings with key stakeholders.
- Must be proficient in Microsoft Office Products including Word, Excel and PowerPoint.
- Presentation skills
IV. SCOPE OF RESPONSIBILITY:
Does this role supervise/manage other employees? No
V. WORK ENVIRONMENT:
Is Travel Required? Yes. Travel to state wide meetings, physician offices, other locations as needed to support the implementation of programs and to represent Gateway Health.
Employee Referral Level: 2
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.
EEO is The Law
Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity (http://www1.eeoc.gov/employers/upload/eeoc_self_print_poster.pdf)
We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact number below.
For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org