Clinical Operations Manager - Case Management (Rn/Lmsw/Lcsw)

MetroPlusHealth provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlusHealth's network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlusHealth has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.

Position Overview

Under the supervision of the Senior Director of Integrated Case Management, the Clinical Operations Manager, Care Management will serve as critical subject matter expert on all clinical systems and care management processes and workflows. The position provides key support of the clinical care management program operating system, day-to-day perspective on all CM/DM operational workflows, regulatory requirements, and program enhancements. They can identify emerging needs that require system changes to our core operating system, data warehouse, and clinical communications. They collaborate closely with several care management teams with oversight from departmental directors/senior directors to ensure alignment in terms of resource allocation and prioritization of proposed changes/upgrades.

• Provide support of all project management activities for core operating system design and revisions to support care and disease management programs.
• Provide insight to current care management processes including policies in place for relevant lines of business/programs
• Identify, escalate, and address any issues that may impact regulatory compliance as it relates to care management (this includes system failure, operational issues, and audit findings)
• Communicate care management team experiences and pain points as well as successes of current operations using current systems
• Gather and share documentation and demonstrate current-state operations and legacy solution
• Communicate reporting and correspondence needs and serve as a reviewer of the requirements
• Support design of future state process flows and review the associated requirements
• Provide data mapping information and support any application design questions
• Provide feedback on developed solutions for care management
• Identify root cause of complaints or inquiries and implement solutions to prevent issues from reoccurring
• Support critical, systems-oriented problem-solving related to barriers to providing high-quality care management along with other Clinical Operations colleagues
• Support business process, training, and change management efforts by providing insights and feedback
• Serve as a care management champion of system implementation and ongoing maintenance and improvement by consistently communicating implementation benefits and motivating staff to adopt a solutions-focused approach
• Continue to conduct all of the above activities as they relate to the future system and provide support to care management staff post-implementation.

• A Bachelor's Degree in a healthcare-related field required; and
• 8+ years of health care clinical administration; and
• 4+ years of progressively responsible CM experience in a managed care plan; or
• A satisfactory equivalent combination of education, training, and experience
• Excellent process development/management skills to ensure tools, supportive technologies and operational flows are optimally utilized.
• Clinical background; well-versed in informatics, analytics, and decision-making skills
• Ability to work cross-functionally and collaborate across the MetroPlusHealth leadership team.
• Experience with NYS and CMS regulations and compliance.
• A valid, unrestricted New York State Registered Nurse (R.N.) license or social work license (LMSW or LCSW) required.

Professional Competencies

• Customer Focus
• Excellent Microsoft Office Suite skills
• Ability to lead and manage significant change.
• Excellent interpersonal, communications, problem-solving and negotiating skills.