Leader, Care Management Special Needs Plan #786
Status: Full-time, Exempt
The Leader is responsible for leading the development and quality of clinical programs in association with the Medical Director. The Leader will coordinate clinical initiatives with colleagues in the Dual Special Needs Plan (DSNP). The Leader will be responsible for implementing clinical services, care management, disease management programs, and quality initiatives for all program members including but not limited to those with medical, behavioral, physical, intellectual, or developmental disabilities.
Direct clinical and care management programs and support services that will promote the highest standards of quality and appropriate services to members of the DSNP.
Collaborate with the Medical Director to develop, implement, and monitor performance standards for clinical services and care management and fidelity to the model of care.
Create a climate that motivates case and disease management staff to do their best. Emphasizes the importance of individuals' contributions to the team’s success.
Participate with MVP leadership in developing goals, strategies and management practices that will ensure growth, development, and financial success.
Develop strategies to engage providers in the care model to which we are committed and identify those providers who are collaborative.
Recruit, train, develop and maintain a high-quality clinical team of care management professionals.
Plan, develop, implement, and evaluate processes and guidelines for managing care across the healthcare continuum for MVP Health
Care members enrolled in our programs. Ongoing monitoring, evaluation, and revision of diagnostic and utilization triggers and stratification criteria used to identify appropriate members for intervention.
Oversee the development and implementation of various tools that in corporate peer reviewed clinical guidelines represent "best" practices”.
Provide consultation to Quality Improvement, Utilization Management initiatives in association with Medical Director and MVP leadership.
Collaborate with the Network team to develop relationships with providers to grow membership.
Work with external services providers and primary clinical providers to assess and meet members’ care and service needs.
Work with the Medical Director to implement a person-centered, goal-oriented care model across the continuum in conformance with the model of care and state and federal requirements.
Work with the Medical Director and Network Management to identify strengths and weaknesses of the provider network and develop appropriate strategies to address gaps and assure network optimization.
Oversee the administration of members’ benefits according to MVP’s DSNP policies and procedures in all care settings, including service authorization and referral policies, hospital admission and discharge protocols, ancillary services management, and assessment of benefit exceptions.
Prioritize opportunities for optimal member health, safety, independence, and well-being including management strategies based on membership needs and characteristics that will improve member health outcomes.
Facilitates and coordinates development, implementation and evaluation of key care management functions and processes. Works collaboratively with other management teams across MVP that includes strategic business units (SBUs), Medical Directors and other internal staff to ensure integration of key functions and processes.
Works with MCO and Operations teams on building clinical systems to support clinical care and data reporting needs.
Participate in QI Committee, Clinical Operations Committee, and other Committees as defined.
Performs other duties as assigned.
Clinical professional registered nurse with bachelor’s degree in Nursing required. Active professional New York State License required.
Master’s Degree in Nursing, Health Care Management, MBA, or related field, strongly preferred
Current CCM Certification and/or Well Coaching Certification is an asset
5+ years’ experience in nursing management role with an emphasis in care management and coordination required
5+ years management/ supervisory experience in managed care/health insurance with clinical and non-clinical staff required
3-5 years’ managed care experience in case, disease or utilization management required
Experience in working with a Medicare and Medicaid underserved populations special needs population required
Working knowledge of Performance, Process and outcome measures and ability to identify, implement and manage successful processes
Experience in working with intellectual and developmentally disabled populations preferred
Experience with NCQA accreditation and/or CMS/DOH audit process preferred.
Ability to interpret and analyze data necessary to identify trends, evaluate trend impacts operationally, fiscally and from a quality perspective and development and managed corrective action activities
Familiarity with Medicare and State Medicaid programs and hands-on experience with regulatory requirements and reporting.
Familiarity with utilization management process: current, concurrent, prospective, and retrospective review
Demonstrated experience in managing clinical nursing staff including recruitment, education, and training
Excellent communication and relationship development skills with health professionals and business colleagues
Strong leadership, relationship building, and mentoring skills.
Ability to work independently and prioritize multiple assignments to meet deadlines
Highly effective interpersonal and conflict management skills
Ability to use discretion in handling confidential information
Excellent oral and written communication skills
Organizational and Time Management skills
Excellent Customer Service
Strong analytical and critical thinking skills
Knowledge of process development, systems management, policy development and workflow design
Knowledge of chronic health conditions, evidence-based practice guidelines and clinical tools used to demonstrate compliance with practice recommendations
Proven success interacting with sensitive health issues, medical necessity, and service appropriateness
Proficient in the use/application of standard computer applications (Word, Access, Excel, PowerPoint)
Valid NYS Driver’s license with capacity to travel and reliable transportation
MVP Health Care is an Affirmative Action/Equal Opportunity Employer (PDF). We recruit, employ, train, compensate, and promote without regard to race, religion, creed, color, national origin, age, gender, sexual orientation, marital status, disability, genetic information, veteran status, or any other basis, e.g., Pay Transparency (PDF), protected by applicable federal, state or local law. Any person with a disability needing special accommodations to the application process, please contact Human Resources at email@example.com.