Highmark Health Manager Clinical Care Coordination in Pittsburgh, Pennsylvania

Description

GENERAL OVERVIEW:

Manages and coordinates the supervisory staff that has accountability for the case management, medical review, utilization review, quality management and/or health education team & programs. Monitors and evaluates the operational performance of overall departmental direction, leveraging analytics, regional market trends and utilization trends of members to set future direction and refine current state. Develops longer term plans that will improve utilization, quality and clinical outcomes based on market trends, legislative environment and company’s mission, vision and direction. Responsible for the leadership, performance management for supervisory staff as well as company and department objectives, supporting providers in a variety of health care settings to appropriately identify members with chronic conditions and/or gaps in care that can be positively impacted related to quality and care costs. (note that health care settings could include, but not limited to, working in a physician’s office, visiting physician practices on a routine basis, working within a hospital setting and/or assessing and coordinating member’s care within the member’s home).

ESSENTIAL RESPONSIBILITIES:

1.Performs management responsibilities to include, but are not limited to: involved in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity.

2.Plans, organizes, staffs, directs and controls the day-to-day operations of the department; develops and implements policies and programs as necessary; may have budgetary responsibility and authority.

3.Assists in the development of goal-setting and establishing future direction of the operations of a combined case management/utilization management team and assists with operations planning and efficiency.

4.Ensures overall compliance with applicable business process requirements, regulatory requirements and accreditation standards that support all lines of business.

5.Serves as key resource to both supervisory staff and external sources on complex issues, departmental direction and future planning.

6.Develops proposals to improve overall efficiency and managed care experience, utilization, quality and clinical outcomes. Collaborates with supervisor staff and providers for insights to inform future direction and refinement of overall operations. Collaborates with the appropriate cross- functional leadership and external entities to formulate new, innovative ideas to improve departmental performance, reduce costs while enhancing member experience. Works with internal

7.Other duties as assigned or requested.

III. QUALIFICATIONS:

Education, Licenses/Certifications, and Experience (For Experience requirements please see appropriate role/level guide. If not applicable, list experience requirements below.)

Minimum

  • Current PA RN license and/or additional states as required or current Social Work license

  • 4 years of any combination of clinical, case management and/or disease/condition management, provider operations and/or health insurance experience

  • 4 years of management experience

  • Clearances as required by specific practice or hospital, as applicable

Preferred

  • Certification in Case Management (CCM)

  • BSN

  • Utilization Management experience

  • Behavioral health experience

  • Five or more years of any combination of clinical, utilization/case management and/or disease/condition management, provider operations and/or health insurance experience

Knowledge, Skills and Abilities ( This section describes additional preferred characteristics)

  • Proficiency in MS Excel and enhanced data and statistical analysis skills

  • Excellent interpersonal/ consensus building skills as well as the ability to work with a variety of internal and external colleagues from all levels of an organization

  • Broad knowledge of the health care delivery system including an understanding of health care costs drivers

  • Excellent verbal and written communication skills including individual and/or group education/training

  • Experience working with the healthcare needs of diverse populations and understanding the importance of cultural competency in addressing targeted populations.

  • Self-directed; self-starter; ability to work successfully with indirect supervision and moderate autonomy

  • Excellent organizational, time management and project management skills

  • Ability to work in a fast paced, high visibility, high performing team environment that requires flexibility

  • Ability to travel locally and work flexible hours in a practice or facility-based settings

  • Ability to communicate effectively in more than one language, preferred

  • Experience working directly with physicians in provider practice settings, members in a home environment or hospital discharge processes.

IV. SCOPE OF RESPONSIBILITY ( People Management Responsibility)

Does this role supervise/manage other employees?

Yes

V. WORK ENVIRONMENT

Is Travel Required?

Yes

Unusual Working Conditions

This position could include meetings in, and travel to provider locations, external agencies, etc. The position is a dynamic one which will require flexibility in work settings and travel.

REQNUMBER: J120651

Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity