Complex and Disease Case Management Manager

Job Summary :

Responsible for oversight and management of the Complex and Disease Specific Case Management Program and Social Services.

Service area accountabilities include general complex case management, pediatric care coordination services, other specialty disease specific case management programs(DSCM) and social services for all product lines i.

e. (HMO, MultiChoice, Individual Plans and Medicare). This will include daily supervision of the DSCM staff, Case Management Supervisor.

The key department activities to be supervised are assessment of need, planning of care / development of treatment plan, implementation of plan of care, monitoring and coordinating care based on treatment plan, evaluation of case management, social services, communication with member and providers, education, and management of care along the continuum.

Essential Responsibilities :

• Responsible for the monitoring and oversight of case management activities in all product lines and resultant outcomes.
• Works with Chief of Primary Care, Chief of QRM and specialty chiefs to create positive outcomes for high-risk members involved in case management programs.
• Monitoring and outcome accountability of identifying case management QRM quality initiatives.
• Development and implementation of QRM case management improvement plans and disease specific programs.
• Responsible for the supervision of non-physician case management supervisory staff as outlined above.
• Identifies prospective candidates in accordance with established guidelines and evaluates the candidates hiring potential in conjunction with departmental goals.
• Responsible for development and implementation of policies and procedures for areas of accountability.
• Works with QRM Compliance Manager to insure regulatory compliance for areas of accountability.
• Remains knowledgeable of current, relevant state and Federal regulations, criteria, documentation requirements and laws that affect managed care and case / utilization management.

Educates staff and physicians on the changes and the implications of the changes. Ensures that policies and procedures are revised and implemented to meet requirements.

• Assumes oversight and responsibility for his / her respective area as it relates to MDQR and NCQA site visit review preparation and coordination.
• Acts as lead resource for the Case Management Supervisor and the disease specific case management program staff and assists with problem solving and difficult cases.
• Works with supervisor responsible for professional development by participation in staff education and training. Identifies training needs for staff and QRM in general in relation to inpatient and ambulatory review education needs.
• Provides the Director analysis of reported department statistics and activities as needed as well as monthly report of department activities.
• Analyzes reports to determine the need for guidelines, pathways and protocols or other measures that will improve the utilization of resources.
• Interacts with the Chief of QRM, Chiefs of Service and other QRM Managers as needed to solve problems and assist with difficult cases.
• Determines staffing requirements to ensure that case management services are rendered in the most effective and efficient manner.
• Develops individual performance objectives for management staff and ensures that competence of staff meets departmental standards.
• Builds effective working relationships with physicians, hospital staff, vendors, and other departments within the health plan.
• Interviews, hires, trains, disciplines, evaluate, counsels and terminate in conformance with EEO / AA goals, personnel policies, and organizational objectives.
• Attends health care team meetings as needed.
• Attends Hospital Analysis Work Group Meetings as needed.
• Collaborates with the Manager of Inpatient and Specialty Review Services to ensure continuity of care.
• Assists in the preparation and conduction of QRM staff meetings, in conjunction with the other QRM Managers.
• Investigates, identifies and reports problems and inefficiencies in existing systems, and recommends changes when appropriate to the Director.
• Recommends to the Director revision of service area criteria and goals as needed.
• Plans and participates in the orientation of newly contracted providers and facilities as requested; assists with contract maintenance of ancillary providers at the request of Community Medical Services.
• QRM representative to the CVD and EIQ Workgroups and Population Care Managers Meetings.
• Represents the Georgia market in interregional activities when necessary / requested.
• Works cross-functionally with other departments in striving to meet organizational goals and objectives.
• Participates in Marketing RFI / RFP process, information gathering, and group meetings as requested.
• Acts as a team coach for respective areas of responsibility regarding enhanced customer service, quality of work performed and productivity of staff.
• Responsible for budget development and accountability for areas of accountability.
• Achieves and maintains an understanding of relevant state and federal regulations, criteria, and documentation requirements and laws that affect managed care, home health and case / disease management.
• Knowledgeable and compliant with regional personnel policies and procedures.
• Knowledgeable and compliant with QRM departmental and unit specific policies and procedures.
• Participates in annual regional and departmental compliance training.
• Knowledgeable and compliant with Principles of Responsibility.
• Consistently supports compliance and the Principles of Responsibility (Kaiser Permanentes Code of Conduct) by maintaining the privacy and confidentiality of information, protecting the assets of the organization, acting with ethics and integrity, reporting non-compliance, and adhering to applicable federal, state and local laws and regulations, accreditation and licenser requirements (if applicable), and Kaiser Permanentes policies and procedures.
• Responsible for assisting the Medical Office Administration, Customer Services and Provider Relations in investigating concerns and issues.
• Access to protected health information (PHI) will be limited to the minimum necessary required to effectively perform the job.
• Demonstrates understanding of HIPAA privacy regulations
2 days ago