Clinical Programs Manager Rn

Join our team as our new Clinical Programs Trainer, RN, with Health Plan of San Joaquin! This position is remote - must reside in the state of California.

What You Will Be Doing:

Under general direction, the Clinical Programs Trainer provides support for Medical Management initiatives to ensure an efficient and effective workforce that is in compliance with the state, federal and other regulatory entities. This position is a Clinical Lead for new Medical Management projects. Work is varied and moderately complex and requires a moderate degree of discretion and independent judgment.

Our Vision:

Continuously improve the health of our community.

Our Mission:

We provide healthcare value and advance wellness through community partnerships.

Essential Job Functions:

• Performs as a subject matter expert for online clinical systems and clinical work processes for the clinical services teams (UM, CM, QI, Pharmacy).
• Provide training and quality checks through side-by-side coaching, formal subject- specific training, random and scheduled quality process audits, and other projects as assigned.
• Provide System Training for all new employees and established employees, including Medical Directors and performs skill competency assessments and work performance and quality audits, utilizing standards and metrics established as benchmarks for performance, in the orientation period ongoing as established.
• Identifies overall performance gaps as well as individual gaps and works with management to identify and implement tactics to improve performance.
• Develops job aids and other tools to support learning performances improvement.
• Research and problem-solves production results that fall outside of established thresholds for production standards and identifies opportunities for improvement.
• Identifies trends and possible root causes and recommends improvement opportunities to management for attaining consistent production performances against established standards and to achieve workflow efficiencies.
• Leads or actively participates in technical systems rollouts, enhancements, and upgrades, in alignment with key departments, to assure consistent application in clinical departments.
• Manages the workflow components of the online systems for authorizations and case management, including the creation and revision of work queues, the adjustment of workflow decision trees, and the addition/maintenance of documentation tools such as automated letters.
• Manages the auto authorization components of the online system and follows the standardized procedure for review and implementation of business rules as authorized through the established oversight committee.
• Participates in the identification and analysis of clinical workflows, recommends solutions, and collaborates in the implementation of workflow efficiency initiatives.
• Responsible for the annual Inter-Rater Reliability Testing for staff (Physician and Nurses).
• Participates in the identification and development of production reports to support monitoring of business results.

What You Bring (required):

• Produces work that is accurate and complete.
• Produces the appropriate amount of work.
• Actively learns through experimentation when tackling new problems, using both successes and failures to learn.
• Rebounds from setbacks and adversity when facing difficult situations.
• Knows the most effective and efficient process to get things done, with a focus on continuous improvement.
• Strong knowledge of health plan operations and interdependencies.
• Strong knowledge of audit, control and monitoring processes, and the ability to effectively implement and maintain them.
• Strong knowledge of managed care reimbursement processes.
• Strong knowledge of medical management processes and best practices.
• Basic knowledge of NCQA accreditation requirements.
• Strong knowledge of medical management technologies.
• Strong skills in analysis - data identification, integration, validation, manipulation, interpretation, and reporting; ability to interpret and determine the impact of complex laws, regulations and other documents.
• Basic knowledge of NCQA requirements related to medical management.
• Time management and organizational skills. Uses time effectively and efficiently. Values time. Concentrates his/her efforts on the more important priorities. Can attend to a broader range of activities. Meets deadlines.
• Strong problem-solving skills.
• Commitment to and ability to facilitate an atmosphere of collaboration and teamwork.
• Strong oral and written communication skills with the ability to communicate professionally effectively to diverse individuals and groups. Includes the ability to effectively explain complex information.
• Interpersonal skills - interacts effectively with individuals both inside and outside of HPSJ; relates openly and comfortably with diverse groups of people.

• Strong teaching and coaching skills, with the ability to give performance feedback constructively and effectively.
• Demonstrated ability to articulate and embrace organizational values, integrate into management practices, and foster their manifestation among staff.
• Intermediate Word and Excel skills.
• Ability to speak and be understood in English.
• Ability to handle confidential information with appropriate discretion.

Education and Experience (required):

• Associate degree in nursing; and
• At least two years related experience and/or training with an understanding of health plan eligibility and health care benefits; or
• Equivalent combination of education and experience.

Licenses, Certifications (required): Current, unrestricted California Registered Nurse license.

What You Will Get - HPSJ Perks!

• Competitive salary
• Robust and affordable health/dental/vision with choices in providers
• Generous paid time off (starting at 3 weeks of PTO, 4 paid floating holidays including employee’s birthday, and 9 paid holidays)
• CalPERS retirement pension program, automatic employer-paid retirements contributions, in addition to voluntary defined contribution plan
• Two flexible spending accounts (FSAs)
• Employer-Paid Term Life and AD&D Insurance
• Employer-Paid Disability Insurance
• Employer-Paid Life Assistance Program
• Health Advocacy
• Supplemental medical, legal, identity theft protection
• Access to exclusive discount mall
• Education and training reimbursement in addition to employer-paid elective learning courses.
• A chance to work for an organization that is mission-driven – our members and community are at the core of everything we do.
• A shorter commute ­– if you’re commuting from the Central Valley to the Bay Area.
• Visibility and variety – you have a chance to work with people at all levels of the organization, and work on diverse projects.

Job Type: Full-time

Pay: $99,400.00 - $154,000.00 per year

Benefits:

• Dental insurance
• Health insurance
• Health savings account
• Life insurance
• Paid time off
• Tuition reimbursement
• Vision insurance

Schedule:

• 8 hour shift
• Day shift
• Monday to Friday

Location:

• California (Required)

Work Location: Remote