Lead Care Manager

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WVU Medicine

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10.000+ Mitarbeiter

⚕️ Krankenversicherung

Healthcare Insurance

WVU Medicine ist ein umfassendes Gesundheitssystem, das der West Virginia University angegliedert ist und medizinische Dienstleistungen über ein Netz von Krankenhäusern in ganz West Virginia anbietet. Das System umfasst bekannte Einrichtungen wie das J. W. Ruby Memorial Hospital, WVU Medicine Children's und verschiedene andere regionale medizinische Zentren. WVU Medicine bietet eine breite Palette von Gesundheitsdienstleistungen, darunter spezialisierte und fortschrittliche medizinische Behandlungen wie roboterassistierte Herzchirurgie. Es ist auch in der medizinischen Ausbildung, Forschung und in gesundheitsbezogenen Gemeinschaftsinitiativen aktiv und betont eine Mission, der Gemeinschaft, die es bedient, hochwertige Versorgung zu bieten.

Beschreibung

• 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

🎯 Anforderungen

• 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

🏖️ Vorteile

• Some travel may be required to offsite meetings