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Form of workPOSITION SUMMARY
Provides supervision to the Clinical Case Managers in Community Health Group’s (CHG’s) High-Risk Case Management program, and is responsible for the optimal and timely delivery of proactive and collaborative Case Management and care coordination activities.
COMPLIANCE WITH REGULATIONS
Works closely with all departments necessary to ensure that the processes, programs, and services are accomplished in a timely and efficient manner by CHG policies and procedures and in compliance with applicable state and federal regulations including CMS and/or Medicare Part D, DHCS, and DHMC.
RESPONSIBILITIES
Supervises staff in day-to-day functions, including training and developing the Case Management and care coordination staff to accomplish program goals and objectives.
Assists in the development, maintenance, and implementation of metrics to appraise the productivity and quality of staff performance.
Supervises the management and care coordination of identified high-risk members to reduce recurrent and unnecessary hospital admissions, readmissions, and emergency room visits.
Works in close collaboration with Interdisciplinary Care Team and contracted physician groups who conduct assessments to establish members' care needs.
Supervises the process to promote smooth transitions of care for targeted members.
Coordinates individually needed interventions for select members based on CHG-established indicators.
Guides case managers and care coordinators with difficult cases and situations; assumes responsibility for cases when risk management issues are identified.
The Health Care Services management team works to develop, implement, and evaluate interventions designed to enhance member outcomes, and quality metrics, and increase customer satisfaction.
Functions as a resource to internal and external customers.
Qualifications
EDUCATION
Graduate from an accredited school of nursing or other clinical-related field required
A BA degree in a health-related field preferred
Certification in Case Management is preferred.
EXPERIENCE/SKILLS
2 years experience as a high-risk case manager and 1-year experience in a managed care environment, hospital discharge planning, or outpatient clinic is required.
1 year of supervisory experience preferred.
Knowledge of population health, care/Case Management clinical operations, and management expertise relating to business planning, process improvement, budget administration, and personnel management.
Working knowledge of Microsoft programs; proficiency with Word and Excel.
Knowledge of managed care principles, CPT, ICD-10, HCPCS coding, and experience with inpatient and outpatient medical review guidelines (MCG).
Familiar with Medi-Cal, and Medicare. Familiar with Web-based standard of care sites i.e. NIH, ACOG.
Ability to communicate effectively verbally and in writing; exceptional telephone and customer service skills; ability to establish effective working relationships with physicians and medical professionals;
May be required to conduct in-person visits and assessment of members.
OTHER REQUIREMENTS
Prolonged periods of sitting at a desk; intermittent standing, walking, and bending.
May be necessary to work and attend meetings outside of the facility or during normal business hours.
Lifting 10 lb. or less.
Driving within the County of San Diego
California driver’s license in good standing.
**Must have current authorization to work in the USA**
Community Health Group is an equal-opportunity employer that is committed to diversity and inclusion in the workplace. We prohibit discrimination and harassment based on any protected characteristic as outlined by federal, state, or local laws. This policy applies to all employment practices within our organization, including hiring, recruiting, promotion, termination, layoff, recall, leave of absence, compensation, benefits, training, and apprenticeship. Community Health Group makes hiring decisions based solely on qualifications, merit, and business needs at the time. For more information, see Personnel Policy 3101 Equal Employment Opportunity/Affirmative Action.
