Lead Care Manager

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WVU Medicine

SiteLinkedInTodas as Vagas

10.000+ funcionários

⚕️ Seguro de Saúde

Healthcare Insurance

WVU Medicine é um sistema de saúde abrangente afiliado à West Virginia University, fornecendo serviços médicos através de uma rede de hospitais em todo o estado da Virgínia Ocidental. O sistema inclui instalações notáveis como o J. W. Ruby Memorial Hospital, WVU Medicine Children's, e vários outros centros médicos regionais. WVU Medicine oferece uma ampla gama de serviços de saúde, incluindo tratamentos médicos especializados e avançados, como cirurgia cardíaca robótica. Também está envolvido na educação médica, pesquisa e iniciativas de saúde comunitária, enfatizando a missão de fornecer cuidados de alta qualidade às comunidades que serve.

Descrição

• Participate in activities related to care management program build, implementation, oversight, and delegation • Assist in ensuring compliance with CMS SNP Model of Care (MOC) expectations, NCQA standards, and Medicare Advantage regulatory requirements • Assists in the development and implementation of policies and procedures related to the Care Management process • Assists with monitoring performance standards, productivity and ensuring staff coverage to meet the needs of the department • Formulates, implements and evaluates educational strategies for staff • Maintains a working knowledge of the requirements of regulatory and compliance entities • Mentors new Care Managers and assists with training • Provides support and coaching to Care Managers and other clinical team members • Perform data collection and analysis of trends to determine areas of opportunity and strategies for better practices for the Care Management team • Takes escalated calls or fills-in for the Care Manager team during high-peak periods • Assist in quarterly reporting of delegated case management processes to meet accreditation standards • Assist in submission of required documents/policies during application process to accrediting body • Provides clinical, procedural or interpretational assistance • Ability to present complex ideas and data to a wide variety of stakeholders from frontline employees to executive c-suite • Establishes and maintains cooperative and positive working relationships with key stakeholders across the organization • Participates in the Interdisciplinary Care Team (ICT) in conjunction with the SNP CM team, PCP and beneficiary/caregiver • Assists in using Peak Health’s analytics tools to monitor HRA timeliness, care plan compliance, ICT effectiveness, utilization trends, and quality outcomes • Serve as a key liaison between SNP Care Management, Peak Health providers, pharmacy, behavioral health partners, and community agencies • Support escalation and review of high-risk, high-need member cases to ensure appropriate interventions, community resource connections, and care plan adjustments • Assist Peak’s Quality Management and Compliance teams to support Stars improvement, HEDIS performance, utilization management coordination, and audit readiness • Support escalation and review of high-risk, high-need member cases to ensure appropriate interventions, community resource connections, and care plan adjustments

🎯 Requisitos

• Current Registered Nurse license issued by the state in which services will be provided or current multi-state Registered Nurse license through the enhanced Nurse Licensure Compact (eNLC) • Five (5) years of healthcare clinical experience • Two (2) years’ Care Management, Case Management or Population Health experience • Bachelor's Degree in Nursing OR Associate of Science in Nursing Degree (ASN) or Diploma • Management of Medicare and/or Medicaid and/ or SNP populations • One (1) year SNP Care Management experience

🏖️ Benefícios

• Some travel may be required to offsite meetings