Job Summary:
The position is responsible for leading the Dual Special Needs Plan (DSNP) clinical care team in a hands-on manner to provide exceptional service to the customer and contain medical claims cost. This is accomplished through active involvement and leading of the day-to-day operations of a clinical care team and ensuring staff is consistent with corporate policies and procedures and are compliant with contractual, state and federal guidelines. Serves as a medical resource to members and providers, and non-clinical staff.
Responsibilities:
Supervises, analyzes and coordinates the daily activities of the unit to ensure departmental productive goals are met with regards to quality timeliness, accuracy and consistency of medical decisions.
Continuously evaluates workflow issues and seek to improve processes that impact the managed long term support and services department.
Coordinates data collection, reviews compliance reports and identifies opportunities for service improvements.
Recommends, develops and implements department policies and procedures and interfaces with other areas to insure consistent applications.
Liaison between Medical Directors and staff.
Ensures staff meets all regulatory requirements and comprehends and complies with best practices, professional standards, internal policies, and procedures.
Performs the operational duties of a specific clinical care team.
Develops key performance indicators to evaluate level of service for internal and external customers.
Acts as technical expert and reference point for difficult and complex matters.
Assists Manager in coordinating regulatory, quality and accreditation activities.
Manage, develop and train staff; develop and monitor goals; conduct annual performance reviews, and administers salaries for the staff.
Knowledge:
Requires knowledge of Utilization Management (UM) and managed care principles as they relate to the CCM process and Elderly Frail /Managed Medicaid Population based CM.
Requires knowledge of the Case Management/Disease Management Standards of Practice.
Requires knowledge of health care systems and medical documentation.
Requires understanding of claims processing, contracting and enrollment.
Requires knowledge of State Mandates and Regulations, including HIPAA and HCQA.
Requires knowledge of regulatory bodies and their processes including HCFA and DOBI.
Requires knowledge of NCQA and URAC accreditation criteria related specifically to UM/DM and Case Management.
Requires knowledge of community health resources.