Director of Case Management (RN) Hybrid

Under the supervision of the Senior Director of Integrated Care Management (ICM), the Director of ICM (Medicare) provides clinical and administrative oversight for the Medicare Advantage and Integrated Benefits for Dually Eligible (“IB-Dual”) populations, also known as the Medicare dual eligible special needs plan (D-SNP) line of business. This role ensures adherence to the Medicare Model of Care, CMS regulatory requirements, established policies and workflows. They are also responsible for managing the day-to-day operations of the clinical and non-clinical staff, ensuring adherence to the care management process. Most broadly, the Director ensures members are receiving the care they need and that staff are addressing the members’ medical, behavioral and social needs while ensuring appropriate linkages in order for them to remain safely in the community.

Job Description

• Participates in the development of the vision and strategic direction for Integrated Care Management; collaborates on the implementation of related strategies.
• Supervises, plans, organizes, prioritizes, delegates, and evaluates staff and functions of the Integrated Care Management Department and Medicare line of business.
• Ensure staff are care managing members in accordance with the risk stratification identified and adhering to the care management process of screening, assessing, implementing, and evaluating.
• Participates in development, implementation, and annual review of the Integrated Care Management and Quality Management / Quality Improvement Plan.
• Provides oversight for the implementation and adherence to the Model of Care
• Ensures compliance with Federal, State and City regulations as they relate to Medicare, Medicaid, and Health Homes.
• Provides oversight for Transitions of Care Process and tracking, implementing strategies to prevent readmissions and reduce hospitalizations.
• Collaborates with NYC H+H and external partners on various initiatives, projects and pilot programs.
• Gathers, develops and tracks data on evidence-based practice interventions.
• Represents ICM at various meetings and committees as required.
• Provides clinical support for the review of Quality-of-Care concerns being investigated by the Quality Management Department, and collaborates with Quality Management on HEDIS, STAR ratings and CAHPS score improvement initiatives and strategies.
• Collaborates with the UM Department to manage appropriate member utilization and works with data analytics to generate reports that will illustrate the impact on members' utilization.
• Drives the implementation of processes and functional enhancements which will improve the overall quality and services provided by the CM teams.
• Collaborate with customer service department to ensure that member issues and concerns are addressed and resolved in a timely manner.
• Analyzes trends and implements departmental initiatives based upon data provided through the reporting of Care Management or from Quality, Data Analytics and Audit data.
• Ensures comprehensive and supportive on-boarding of new hires and effective, data-driven monitoring / coaching to ensure that efficiency and performance are maximized among existing staff.
• Maintains communication with the department head, offering routine updates on operations, issues, concerns, and other pertinent information.
• Performs other duties as assigned by the Senior Director.

Requirements

Minimum Qualifications

Licensure and / or Certification Required :