Lead Care Manager – PEAK

🕒 2 days ago

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Peak Health

WebsiteLinkedInAll Job Openings

51 - 200 employees

⚕️ Healthcare Insurance

🤝 Non-profit

Healthcare Insurance • Non-profit

Peak Health is a health insurer and health insurance services company headquartered in Morgantown, West Virginia. It is owned by three not-for-profit health care providers: WVU Health System, Marshall Health Network, and Valley Health. Peak Health aims to improve community health outcomes by offering an inclusive, provider-led health plan for residents of West Virginia and surrounding areas. The company is committed to making health care more accessible, understandable, and collaborative, with a focus on reducing costs and administrative fees for patients and employers. Peak Health also offers Medicare Advantage coverage tailored for West Virginia seniors through partnerships with leading health systems.

📋 Description

• Onboarding new employees and mentoring members of the SNP care management team • Providing education, performing documentation audits, and building clinical team members expertise through direct feedback and real-time coaching • 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

🎯 Requirements

• 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

🏖️ Benefits

• Health insurance • Paid time off • Flexible work arrangements • Professional development opportunities