Manager of Medical Care Management / 13-4152 at Medford

Position Description:

The Manager of Medical Care Management assists in the development, implementation, and operational oversight of the medical care management team, a functional component of the Integrated Care Management Department.  This manager is also responsible for case triage and assignment, case audit, and clinical-quality data reporting.

The Manager of Medical Care Management collaborates with the other departments within Clinical Affairs as well as with departments outside of Clinical Affairs to ensure that departmental and organizational goals and objectives are met.  Such goals may include but are not limited to supporting Medicaid state quality improvement project (QIP) requirements, improvement initiatives for HEDIS measures compliance with NCQA standards and/or addressing appropriate medical expenses. 

This Manager of Medical Care Management promotes the mission and values of the Clinical Affairs Department, Network Health, and Tufts Health Plan.

PRINCIPAL DUTIES AND RESPONSIBILITIES:

ESSENTIAL FUNCTIONS:

Using Network Health member experience, industry best practice standards, quality initiatives, and contractual requirements identifies the need for potential new or enhanced case/care management initiatives and works with the leadership of the Integrated Care Management team in developing and implementing those initiatives/enhancements that will have the most positive impact from both quality of care and cost perspectives for members with chronic disease and complex medical problems. 

In conjunction with Director of Integrated Care Management, develops reports for care management that are aligned with strategic clinical-quality and financial goals in support of departmental and organizational initiatives. In addition, defines metrics and goals for the medical care management team and creates a supportive, coaching environment to help team members achieve their goals.

Provides liaison and contract management between vendors and Network Health in coordinating health coaching and other activities.

Provides required state and contractually required reports per schedule.

Is directly responsible for supervision, training, and mentoring of medical care management staff and daily operations of the medical care management department.

Provides monthly metrics supporting process and outcome impacts of medical care management activities.

Leads medical care management team meetings; participates in integrated care management team meetings.

Collaborates with other clinical affairs managers to ensure integrated delivery of health car services and seamless transitions between teams.

Participates in the care management workflow application ongoing improvement team.

OTHER JOB FUNCTIONS:

Attends internal and external meetings as required as a representative of the Integrated Care Management department.

Maintains professional growth and development through self-directed learning activities and involvement in professional, civic, and/or community organizations.

Other duties as assigned.

Qualifications:

Education:

• RN required. Masters level degree preferred.  CCM preferred.

Skills/Experience:

• 5 years experience in a health plan is strongly preferred.
• 3 years supervisory experience preferred.
• Recent care/case management experience or recent clinical experience required.
• Knowledge of Medicare and Medicaid experience with regulatory, compliance, and reporting requirements.
• Experience with Clinical Screening Criteria required.
• Experience with the principles of case management strongly preferred.
• Experience with McKesson’s Care Enhance Clinical  Management Software (CCMS) and McKesson’s InterQual Clinical Screening Criteria a plus.

Certificate/License:

• RN with current license in Massachusetts without restriction

Country: USA, State: Massachusetts, City: Medford, Company: Network Health.