OVERVIEW OF POSITION:
Responsible for the oversight, management and optimization of all CQI, UM and Care Management activities as they relate to inpatient, social service, home health, DME and other healthcare delivery programs within Healthcare Partners Medical Group. Participates in the development, implementation and maintenance of all programs to ensure that patient care maximizes quality and continuity by utilization of appropriate resources and alternatives to inpatient care within the parameters of health plan benefits and established contracts. Ensures consistency and standardization of the application of these healthcare delivery programs across the regions, and the integration of these programs within the IPA model. Works with other members of the Regional Accountable Team (RAT) to ensure the clinical, quality, financial and patient satisfaction outcomes of the region. Works closely with all members of RAT as well as Health Enhancement, Quality Improvement, Contracting and the Office of the Medical Director.
Consistently exhibits behavior and communication skills that demonstrate HealthCare Partners’ (HCP) commitment to superior customer service, including quality, care and concern with each and every internal and external customer.
Identifies need for and participates in the development and implementation of care management and utilization management policies and procedures, and ensures compliance throughout the region and consistency throughout the network.
Monitors closely and analyzes all inpatient and outpatient reports and identifies trends. Makes recommendations to the Regional Accountable Team (RAT) regarding interventions to improve all resource management.
Develops and coordinates strategies for ensuring the delivery of care in the most appropriate setting.
Ensures that contracted providers are used and collaborates with Contracting department to obtain new contracts with preferred providers based upon specific quality and utilization criteria.
Monitors of all high-risk/high-cost patients in regard to care delivery, referrals, contracting, etc. Oversees cross-regional high-cost areas of Care Management (i.e., transplant or high-volume complex lines of business such as IPA/group).
Monitors provider referral patterns for appropriate utilization of specialty and ancillary services.
Initiates organizational and system changes to improve departmental staffing efficiency and effectiveness, and care management program outcomes within the region.
Coordinates or performs projects/activities as delegated by organizational committees and Supervisor.
Participates and supports organizational committees as appropriate including the Regional Care Management Committees per regulatory guidelines.
Identifies, develops and oversees the educational needs of the Care Management providers and staff including the implementation of an extensive orientation program, cross-training and proactive approach to Care management.
Identifies opportunities for the development of new care management approaches and prepares proposals with cost analysis, IS requirements, educational needs and implementation plan to be presented to the centralized team for network-wide implementation.
Develops and manages regional business plans and budget with RAT.
Motivates and leads the Care Management staff in setting and reaching goals for continuous improvement in quality, service and cost-effective care to all HCP customers.
Uses, protects, and discloses HCP patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards.
Performs additional duties as assigned.
Bachelor’s degree from a four-year college and/or a professional certification requiring formal education beyond a two-year college.
Master’s degree preferred.
Degree in Nursing, Healthcare Administration or related field preferred.
Over 5 years and up to and including 7 years of experience
5 years of management experience in a medical group, IPA or HMO setting.
Experience in the creation and implementation of outcome measures of new programs.
KNOWLEDGE, SKILLS, ABILITIES:
Proficient in Microsoft Office applications.
Demonstrated effective management abilities.
Excellent verbal and written communication skills.
Ability to work cooperatively with peers and subordinates.
Ability to act professionally under pressure.