Manager, Care Manager 8/20/2016
Wilkes Barre, PA
JOB DESCRIPTIONAPPLY GENERAL OVERVIEW:
Expert in the areas of utilization management, continuum of care planning, benefit interpretation, insurance industry regulations as well as personnel management. Accountable for the oversight; development and maintenance of the department's utilization management processes which includes strategic planning, care cost initiatives, system development and quality outcomes. Responsible for compliance to NCQA, URAC, CMS, DOH, and DOL regulations. Coordinates all department activities; staff education, policy and procedure development and revision, care audits, oversees overall operations such as call volumes, referrals to disease management programs and quality assurance. Responsible for appropriate application of Medical Policy and criteria. Communicating and executing corporate initiatives. Management and control of departmental expenditures defined by cost center allocation.
ESSENTIAL JOB FUNCTIONS:
* Development, implementation, and measurement of department, corporate, and utilization management objectives.
* Recruitment, selection, orientation, performance measurement; counseling, and performance improvement planning; promotion and termination per corporate policy; and career development and support of staff.
* Constantly evaluate the utilization management markets and incorporate the needs of the healthcare environment into the utilization management programs.
* Assure the development of teams which are focused on exceeding the utilization management objectives through team building sessions, team work facilitation, committee opportunities and leadership opportunities.
* Develop and coordinate cross-functional/interdepartmental relationships which enhance the overall care delivery and outcomes for our customers.
* Uphold and demonstrate Highmark's mission and corporate values.
2. Data Analysis/Outcomes
* Assist in the analysis of clinical data elements and present data analysis to a wide range of audiances
* Assure implementation and measurement of high performance standards.
* Provide direct reports with guidance and educational tools in order to assure compliance with a minimal individual audit score that meets department standards.
* Coordinate the development of the utilization management tools and processes required of an efficient and effective program.
* In collaboration with other units and divisions, establish guidelines that quantify measurable utilization management value, benefit, and outcomes.
* Coordinate and implement processes which require and enhance direct report accountability.
* Assure that direct reports achieve the minimal qualification of their positions through ongoing staff development, counseling, and guidance.
* Describe and document outcomes in the Program Description for presentation at the Care Management Committee
* Daily accountability for triage, crisis intervention and referral activities.
3. Project Management
* Identify, develop, and implement division/department projects focused on quality, utilization, process and/or outcome improvements.
* Identify industry benchmarks through scientific research to assure operations exceed industry standards.
* Function in the role of project leader demonstrating commitment and responsibility to the project's success.
* Represent the department by participation throughout the corporation on projects and committees.
* Manage multiple projects and effectively communicate relevant project information to leadership.
* Delver engaging, informative and well organized presentations.
* Develop and implement processes which assure 24-hour availability of utilization management expertise.
* Develop action plans which promote, support and improve utilization management functions on an ongoing basis.
* Develop and implement action plans designed to achieve and enhance compliance to accreditation standards in accordance with NCQA, URAC, CMS, DOH, and DOL regulations.
* Work in concert with all corporate divisions and departments to develop strategies supportive of the corporate mission and vision.
* Assessing and recommending budget requirements and responsible for budget preparation to cost-effectively and efficiently operate departmental programs.
* Monitor monthly budget for variances, initiating cost savings while maintaining highly efficient operations.
6. Other duties as assigned or requested.
* Current, valid, unrestricted license in one or more of the following disciplines: RN, LCSW, LSW, LPC, or other related clinical license
* 3-5 years clinical experience is required
* 7-10 years experience in the insurance or related industry
* Master's degree in a related human services field.
* 3-5 years management.
* Experience in project management.