Company :

Job Description : 

GENERAL OVERVIEW:

Responsible for the strategic development of clinical care management. Responsible for directing the clinical operations of care management and establish highly reliable business processes and technology systems that produce benchmark results in performance. Serves as a role model in leading complex systems and decision processes and customer management that uphold the values, business objectives and service expectations of the organization.

ESSENTIAL RESPONSIBILITIES:

• Leads the development and oversees the execution of policies and procedures.
• Directs the standardization of CM policies, practices workflow and data reporting within the system. Maintains quality patient care and adheres to all relevant compliance activities.
• Accustomed to managing through KPIs and provide education/driving towards improvement. Creates consistency/standard work. Manages people daily through EPIC (core system). Develops trust, cooperation and collaboration with administrative medical staff and departments across the system. (60%)
• Establishes strategic, tactical and financial plans to optimize the efficacy of clinical operations and utilization management.
• Maintains work plans and annual goals with quarterly results reporting systems that demonstrate performance improvement trends. (20%)
• Leads the development of effective communication with internal and external customers to coordinate and adequately address patient care needs. Collaborates with utilization management and revenue cycle to ensure processes are aligned. Develops utilization targets in collaboration with system physician and nursing leadership. Provides accurate and pertinent information to appropriate departments, administration, medical staff and other involved with CM activities. Understands compliance from a Case Management perspective. (10%)
• Reviews data for trends and analyzes the impact on department operations. Leads the implementation of improved clinical care management models utilization management systems to decrease re-admissions, recidivism and excessive length of stay and medical denials. Responds to regulatory changes. (10%)

QUALIFICATIONS:

Minimum

• Bachelor’s degree in Nursing, Business, Health Care Management or related field
• 7 years of management experience in healthcare insurance or healthcare industry with a nursing background, preferably utilization management and related clinical operations

Preferred

• Master’s degree

Additional Employment Requirements:

• Act 34 Criminal Background Clearance Certificate.
• Act 33 Child Abuse Clearance Certificate.
• Act 73 FBI Fingerprinting Criminal Background Clearance Certificate.

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times.  In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. 

Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.

California Consumer Privacy Act Employees, Contractors, and Applicants Notice