Manager, Case Management Services Job in Willoughby, Ohio US
Manager, Case Management Services
Provide oversight and leadership to the Case Management Team to achieve a purposeful and controlled connection between the quality of care and the cost of care across the continuum. Provide complex case management services to those persons who are identified as high risk, resource intense, catastrophic, and those with complex psychosocial and financial issues which may impact the management and outcome of care. Manages day to day operations for the Case Management team. Essential Functions: - Validate the use of specific data reports to identify the appropriate member population: Large claims files; hospital, SNF or LTAC discharge reports; Pharmacy utilization reports and other methodologies based primarily on predictive modeling criteria. Ensure timely retrieval, review, and follow up of cases referred to the Case Management Team through use of available reports available per Tapestry Case Management. Effectively manage and coordinate the assignment of appropriate referrals. Assume accountability for satisfying NCQA standards compliance with reference to Case Management. - Establish processes, department level competencies, and procedures to support Case Management operations. Provide coaching, mentoring, and ensure adequate orientation to Case Management methodologies for all new hires and existing team members. - Develop measurable short and long term goals for the department. Ensure goals are appropriately cascaded from the Region's overall goals. Identify time frame for re-evaluation and identify individual or organizational barriers to meeting goals and complying with intended outcomes. - Develop process indicators related to documentation of comprehensive case management services and monitor adequacy of the team's documentation as a portion of the departments overall quality monitoring processes: depression screening; pain assessment; medication usage assessment; life planning including Advanced Directives; cognitive assessment, functional assessment; assessment of caregiver resources; assessment of cultural and linguistic needs and assessment of available benefits. Use methods such as grand rounds and individual counseling to address variances from pre-established standards. - Monitor team effectiveness against set performance goals through ongoing review of outcomes based measures including customer satisfaction survey results, hospital readmissions data, patient care experience measures (pain status, improved quality of life), and service measures (amissions/1000, PMPM costs, medication compliance). Coach and counsel team based on achievement of goals and outcomes. Sponsor system changes to support improved performance. Qualifications: Basic Qualifications: - BSN in Nursing. -5 years ofexperience in a medical surgical or critical care setting. -2 years of experience in a leadership or quality related role. Experience in accessing and analyzing utilization and cost based data. - Current, active and unrestricted license to practice as a Registered Nurse in the State of Ohio. - Certification as a Certified Case Manager (CCM) per the Case Management Society of America required upon hire. CCM certification required to maintain continued employment in this position. - Strong communication and presentation skills. - Proven track record of working constructively with all levels of the health care team, particularly with senior leadership. - Strong critical thinking skills. - Excellent verbal and written communication skills. - Knowledge and experience with regulatory and accrediting bodies such as CMS, Ohio Department of Insurance (ODI), Department of Labor (DOL), NCQA and JCAHO. Preferred Qualifications: - Master's of Science in Nursing or equivalent advanced degree. -5 years of experience in a medical surgical or critical care setting in a charge nurse capacity. -2 years of experience in a management role overseeing case management or similar type functions. -5 years of experience in a case management or similar role. - Proven track record of working constructively with all levels of the health care team, particularly with senior leadership.