What are the responsibilities and job description for the Manager, Case Management (Clinical) position at Santa Clara Family Health Plan?

FLSA Status : Exempt

Department : Health Services

Reports To : Director, Case Management

GENERAL DESCRIPTION OF POSITION

The Manager, Case Management (Clinical) is responsible for the direct oversight of internal and external case management processes including the development and implementation of policies, procedures and program development. In addition, the Manager, Case Management (Clinical) is responsible for supervising the Supervisors, Case Management (Clinical) to ensure that quality of coordinated care and cost effective services are available to all members in accordance with all applicable State and Federal regulatory requirements, Santa Clara Family Health Plan (SCFHP) policies and procedures, and business requirements for all lines of business.

ESSENTIAL DUTIES AND RESPONSIBILITIES

To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below.

Collaborate, develop, implement and manage all case management processes for continuous compliance with all applicable State, Federal, National Committee for Quality Assurance (NCQA), SCFHP policies and procedures and general business requirements, for all lines of business. This includes but not limited to Centers for Medicare and Medicaid Services (CMS), Department of Health Care Services (DHCS), and Department of Managed Health Care (DMHC) regulations.
Maintain a thorough knowledge of applicable laws and regulations in order to effectively monitor and ensure compliance with CMS, DHCS, DMHC and other applicable agency and program requirements.
Develop and implement continuous analysis and quality monitoring of all policies and procedures to evaluate staff performance and ensure regulatory compliance, including the development and implementation of effective, measurable corrective action plans to meet targeted strategic outcomes.
Ensure the integration of case management operations into other internal and external teams / departments including Quality, Long Term Services and Support (LTSS) and Behavioral Health (BH).
Develop and track metrics related to program activities including collecting, analyzing and reporting by appropriate reports.
Oversee all non-clinical care coordination staff including personal care coordinators.
Create and maintain process workflows and procedures that are in compliance with regulatory requirements.
Provide strong oversight and regular auditing and monitoring activities to ensure care management program guidelines are followed. Provide all required reports to regulatory agencies and internally to SCFHP management.
Manage other projects and programs as needed that support organizational goals.
Work with internal business units and external stakeholders to ensure program goals are met.
Identify issues, trends and opportunities to improve the program and develop recommendations and implement solutions. Escalate critical issues, problems, and delays to SCFHP management and executive leadership, as needed.
Establish and maintain effective interpersonal relationships with all SCFHP staff, members and / or their authorized representatives, providers and other program or agency representatives.
Attend off-site meetings.
Perform other related duties as required or assigned.

SUPERVISORY / MANAGEMENT RESPONSIBILITIES - (Delete this section if not a supervisory position)

Carries out supervisory / management responsibilities in accordance with the organization's policies, procedures, applicable regulations and laws. Responsibilities include :

Recruiting, interviewing, and hiring.

Developing a high performing department culture and staff. This includes setting the standard for staff / peers and motivating employees to maximize organizational goals and objectives.

Effectively assimilating, training and mentoring staff and (when appropriate), cross training existing staff and initiating retraining. This includes coaching to help increase skills, knowledge and (if applicable) improve performance.

Setting goals and planning, assigning, and directing work consistent with said goals. This includes responding to employees' needs, ensuring they have the necessary resources to do their work.

Appraising performance, rewarding and disciplining employees, addressing complaints and resolving issues. This includes providing regular and effective feedback to employees and completing timely and objective performance reviews.

REQUIREMENTS - Required (R) Desired (D)

The requirements listed below are representative of the knowledge, skill, and / or ability required or desired.

Active and unrestricted Registered Nurse (RN) or Licensed Clinical Social Worker (LCSW) license in the state of California. (R)

Bachelor's degree in a healthcare or related field; or equivalent experience, training, or coursework. (R)

Master's Degree in healthcare or related field. (D)

Certification in Case Management. (D)

Minimum two years of progressively responsible experience in a supervisory capacity in case management or utilization management in a managed care or health care setting. (R)

Demonstrated knowledge of Medicare and Medi-Cal benefits, Centers for Medicare and Medicaid Services (CMS), Department of Health Care Services (DHCS) and Department of Managed Health Care (DMHC) regulations. (R)

Demonstrated knowledge of National Committee for Quality Assurance (NCQA) Standards. (R)

Knowledge of local health care community including medical, housing, behavioral health, and social services. (D)

Ability to consistently meet accuracy and timeline requirements to maintain regulatory requirements. (R)

Superior communication skills and ability to effectively facilitate meetings and deliver information / presentations. (R)

Working knowledge of and the ability to efficiently operate all applicable computer software including computer applications such as Outlook, Word, Excel, and specific case management programs. (R)

Ability to use a keyboard with moderate speed and high level of accuracy. (R)

Maintenance of a valid California Driver's License and acceptable driving record in order to drive to and from offsite meetings or events; or ability to use other means of transportation to attend offsite meetings or events. (R)

Excellent written, verbal, and interpersonal communication skills including the ability to express oneself clearly and concisely when providing service to SCFHP internal departments, members, providers and outside entities over the telephone, in person or in writing. (R)

Ability to work with a high level of independence with strong collaboration and relationship management skills. (R)

Strong analytical and problem solving abilities. (R)

Ability to assume responsibility and exercise sound judgment when making decisions within the scope of this position (R)

Ability to think and work under pressure and effectively prioritize and complete tasks within established timeframes. (R)

Ability to comply with all SCFHP policies and procedures (R)

WORKING CONDITIONS

Generally, duties are primarily performed in an office environment while sitting or standing at a desk. Incumbents are subject to regular contact with co-workers, managers, external partners, and vendors in person, by telephone and via work-related electronic communications.

PHYSICAL REQUIREMENTS

Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation :

Mobility Requirements : regular bending at the waist, and reaching overhead, above the shoulders and horizontally, to retrieve and store files and supplies and sit or stand for extended periods of time; (R)

Lifting Requirements : regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds; (R)

Visual Requirements : ability to read information in printed materials and on a computer screen; perform close-up work; clarity of vision is required at 20 inches or less; (R)

Dexterity Requirements : regular use of hands, wrists, and finger movements; ability to perform repetitive motion (keyboard); writing (note-taking); ability to operate a computer keyboard and other office equipment (R)

Hearing / Talking Requirements : ability to hear normal speech, hear and talk to exchange information in person and on telephone; (R)

Reasoning Requirements : ability to think and work effectively under pressure; ability to effectively serve customers; decision making, maintain a concentrated level of attention to information communicated in person and by telephone throughout a typical workday; attention to detail. (R)

ENVIRONMENTAL CONDITIONS

General office conditions. May be exposed to moderate noise levels.

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