Duties/Responsibilities:

Develops and monitors team goals; provides ongoing feedback and coaching; conducts annual performance reviews; leads by example; routinely evaluates staffs clinical skills and technical comprehension; and ensures an atmosphere of open communication, teamwork, and empowerment to make informed decisions

Maintains and recommends appropriate staffing levels to guarantee safe and effective care management

Oversees continuation, coordination, and delivery of individualized care plans and authorized services

Collaborates with each Clinical Operations core areas as needed

Assists in analyzing reviews, metric data, and PHI audits and uses that information to identify opportunities for improvement

Additional duties as assigned

Minimum Qualifications:

Associates degree

NYS RN, LSW or other relevant clinical license

Preferred Qualifications:

CCM certification

Supervisory or training experience

Relevant clinical work experience

Knowledge of member satisfaction/incident management and regulations

Knowledge of quality improvement methodologies

Demonstrated professionalism and leadership skills along with ability to develop, direct, and support a team

Time management, critical/creative thinking, communication, and problem-solving skills

Adept at planning, organizing, and executing

Knowledge of health insurance, Medicaid, Medicare and MLTCP

Care management experience in a clinical managed care environment and knowledge of best practices

Knowledge of UM/QM case philosophies and reporting requirements to state and federal agencies

Ability to allocate, monitor, and control resources while delegating and monitoring workloads

Ability to effectively manage performance as well as set and achieve goals

Compliance & Regulatory Responsibilities:

Ensures Care Management team meets department and regulatory requirements

Guarantees care plans are revised and updated according to regulatory requirements and as a members condition(s) changes in the multiple PHI databases, especially TruCare. Supervises and audits compliance including HIPAA standards, for confidentiality and management of PHI plus Care Management Team entries in varied electronic PHI storage systems (e.g.: Macess, TruCare, and EMR).

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.