Reporting SNP Care Management Leadership, the SNP Lead Care Manager will be an integral member of the health plan’s medical management team. This position is responsible for onboarding new employees and mentoring members of the SNP care management team including providing education, performing documentation audits, and building clinical team members expertise through direct feedback and real-time coaching. This position is committed to the constant pursuit of excellence in improving the health status of our members and community. This team member will have high organizational visibility and responsibility in ensuring overall excellence in all areas of care management.
MINIMUM QUALIFICATIONS
EDUCATION, CERTIFICATION, AND/OR LICENSURE:
1. Current Registered Nurse license issued by the state in which services will be provided or current multi-state Registered Nurse license through the enhanced Nurse Licensure Compact (eNLC).
EXPERIENCE:
1. Five (5) years of healthcare clinical experience.
2. Two (2) years’ Care Management, Case Management or Population Health experience.
PREFERRED QUALIFICATIONS
EDUCATION, CERTIFICATION, AND/OR LICENSURE:
1. Bachelor's Degree in Nursing OR Associate of Science in Nursing Degree (ASN) or Diploma.
EXPERIENCE:
1. Management of Medicare and/or Medicaid and/ or SNP populations.
2. One (1) year SNP Care Management experience.
CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.
1. Participate in activities related to care management program build, implementation, oversight, and delegation.
2. Assist in ensuring compliance with CMS SNP Model of Care (MOC) expectations, NCQA standards, and Medicare Advantage regulatory requirements.
3. Assists in the development and implementation of policies and procedures related to the Care Management process.
4. Assists with monitoring performance standards, productivity and ensuring staff coverage to meet the needs of the department.
5. Formulates, implements and evaluates educational strategies for staff.
6. Maintains a working knowledge of the requirements of regulatory and compliance entities.
7. Mentors new Care Managers and assists with training.
8. Provides support and coaching to Care Managers and other clinical team members.
9. Perform data collection and analysis of trends to determine areas of opportunity and strategies for better practices for the Care Management team.
10. Takes escalated calls or fills-in for the Care Manager team during high-peak periods.
11. Assist in quarterly reporting of delegated case management processes to meet accreditation standards.
12. Assist in submission of required documents/policies during application process to accrediting body.
13. Provides clinical, procedural or interpretational assistance.
14. Ability to present complex ideas and data to a wide variety of stakeholders from frontline employees to executive c-suite.
15. Establishes and maintains cooperative and positive working relationships with key stakeholders across the organization.
16. Participates in the Interdisciplinary Care Team (ICT) in conjunction with the SNP CM team, PCP and beneficiary/caregiver.
17. Assists in using Peak Health’s analytics tools to monitor HRA timeliness, care plan compliance, ICT effectiveness, utilization trends, and quality outcomes.
18. Serve as a key liaison between SNP Care Management, Peak Health providers, pharmacy, behavioral health partners, and community agencies.
19. Support escalation and review of high-risk, high-need member cases to ensure appropriate interventions, community resource connections, and care plan adjustments.
20. Assist Peak’s Quality Management and Compliance teams to support Stars improvement, HEDIS performance, utilization management coordination, and audit readiness.
21. Support escalation and review of high-risk, high-need member cases to ensure appropriate interventions, community resource connections, and care plan adjustments.
PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
1. Ability to stand and walk short distances for eight or more hours.
2. Frequent bending, stooping, or stretching.
3. Ability to lift 30 pounds and push 50 pounds.
WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
1. Standard office environment.
2. Some travel may be required to offsite meetings.
Additional Job Description:
Scheduled Weekly Hours:
40
Shift:
Exempt/Non-Exempt:
United States of America (Exempt)
Company:
PHH Peak Health Holdings
Cost Center:
2403 PHH Medical Management
The West Virginia University Health System, which operates under the brand WVU Medicine, is West Virginia’s largest health system and the state’s largest employer with more than 3,400 licensed beds, 4,600 providers, 35,000 employees, and $7 billion in total operating revenues. The Health System is comprised of 25 hospitals – including J.W. Ruby Memorial Hospital, an 880-bed academic medical center, and the 150-bed WVU Medicine Golisano Children’s Hospital in Morgantown, West Virginia – and five institutes. To learn more, visit WVUMedicine.org.
