Senior Manager of Care Management (43941)

The Senior Manager of Care Management reports directly to the Director of Care Management and is responsible for the auditing, monitoring, assessment, and oversight of processes within the Care Management department for the Medicare lines of business. This position requires a hands-on, data-driven people leader who will have broad accountability for developing, assessing and analyzing comprehensive auditing tools required to ensure standardization and consistency of departmental activities, and departmental compliance to regulatory standards. This role communicates regularly with regulatory entities reporting internal and external compliance and metrics to clinical programs. Reporting to this role are licensed and non-licensed staff.

Duties and Responsibilities:

Responsibilities include, but are not limited to, the following:

• Analyze Medical Management documentation and data, and evaluate department processes to identify opportunities for improvement, including supporting regulatory compliance.
• Collaborate with senior leaders on new and existing clinical programs in alignment with Model of Care
• Provide direction and guidance to the clinical team on contractual requirements and standards, while serving as the subject matter expert and lead on contractual deliverables.

• Engage in ongoing performance management of direct staff including coaching, mentoring, development, training, and succession planning to include hiring and termination decisions Lead ongoing training needs assessment process.
• Develop processes and tools to monitor and ensure quality and consistency in staff performance across all areas medical management.
• Work with Managers to determines root cause for performance deficiencies, and develops improvement strategies for any inconsistencies or gaps identified

• Drive quality and productivity initiatives based on departmental and organization needs
• Responsible for program development, outcomes measurement, KPIs reporting, and contractual oversight.
• Assist in the development and operationalization of new programs that meet regulatory and contractual requirements.
• Ensure clinical standards/requirements are met across all medical management teams, and partner agencies that deliver Care Management services.
• Oversight of the development of tools and processes that ensure clinical program activities comply with the requirements established by contractual & regulatory entities.

• Assist in identifying opportunities and cost/benefit for programs, and enhancements to existing programs, using data analysis tools
• Provide leadership in being the expert on state and federal program requirements, and proposing solutions to department oversight that increase efficiency and improve outcomes
• Work closely with Compliance, Quality, and other stakeholders to help clarify questions and issues related to the operationalization of state and federal requirements, as well as accreditation standards
• Lead a team of licensed and non-licensed staff who support clinical program outcomes
• Provide regular reports and presentations on department quality improvement initiatives, progress toward goals, and performance against standards
• Work with the leadership team to set expectations and targets for quality, productivity, caseloads, and outcomes
• Oversee delegated/accountable entity performance and collaborates with contract managers to align expectations
• Work closely with directors and vice president to ensure initiatives, measurement and content are aligned with expectations
• Attends meetings, and produce reports for contractual and regulatory bodies as required
• Develop, maintain, and ensure execution of quality improvement initiatives
• Other duties as assigned
• Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhood's Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies, and procedures as it applies to individual job duties, the department, and the Company. This position must exercise due diligence to prevent, detect and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates, and/or agents

Qualifications

Required:

• Bachelors Degree in Health-Related Field
• Active, unrestricted Rhode Island Nursing license in good standing. (Consideration will be given to individuals without current RI license. Must provide documentation confirming RI RN application within 24 hours of offer)
• Seven (7) or more years' experience working in a managed care environment, including experience working with Medicare/Medicaid
• Demonstrated experience in clinical quality monitoring and continuous improvement processes
• Outstanding relationship building, negotiation, and conflict resolution skills
• Must display strong analytical and organizational skills and have the ability to identify and implement process improvement strategies with positive business results

• Superior written and verbal communication skills

• Strong interpersonal skills, including effective presentation and listening skills
• Proven ability to develop innovative programs and services

• Ability to lead effective and constructive change
• Demonstrated team building skills
• Commitment to continuous quality improvement
• Ability to represent Medical Management in a variety of settings, including meetings with senior leadership and external partners, including government representatives
• Experience driving performance against contracted specifications and evidenced-based best practice
• Intermediate to Advanced skills in Microsoft Office (Word, Excel, PowerPoint, Outlook)
• Must have access to reliable transportation. If using personal vehicle, must have valid, current drivers license and proof of auto insurance.

Preferred:

• Masters in Health Services, Nursing, Administration or Public Health
• Certified Healthcare Quality Professional

• Certification as a Case Manager from an accredited Case Management program

Neighborhood Health Plan of Rhode Island is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.