Lead Care Manager

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🕒 June 3

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WVU Medicine

WebsiteLinkedInAll Job Openings

10,000+ employees

⚕️ Healthcare Insurance

Healthcare Insurance

WVU Medicine is a comprehensive health system affiliated with West Virginia University, providing medical services through a network of hospitals across West Virginia. The system includes notable facilities such as J. W. Ruby Memorial Hospital, WVU Medicine Children's, and various other regional medical centers. WVU Medicine offers a wide range of healthcare services, including specialized and advanced medical treatments such as robotic heart surgery. It's also involved in medical education, research, and community health initiatives, emphasizing a mission of delivering high-quality care to the communities it serves.

📋 Description

• 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

• Some travel may be required to offsite meetings