Manage the operations and support team within Health Care Services including the Call Center, Utilization Management or Care Management intake & review functions which includes but is not limited to prior authorization, concurrent review (CCR), Claims, skilled nursing facility (SNF) Review and care management services.
Provide oversight and direction for systems and tools used internally by staff and externally by provider partners to assist in Medical or Care Management operations.
Achieve organizational performance standards for Call Center activities, prior authorization, CCR review, SNF review, Claims Audit, Care Management and other areas as deemed appropriate.
Prepare and manages budget for applicable area(s).
Manage coordination of all work, quality improvement activities, projects, objectives and staffing of the department by working with other Managers and Supervisors within Health Care Services.
Evaluate performance and initiates personnel actions such as hiring, merit increases, probationary and periodic reviews, promotions, work plans and disciplinary actions.
Collaborate across Health Care Services departments to assure cross-functional workflow integration in all dependent areas.
Establish and sustain open and transparent communication across divisions and departments within Health Care Services as well as PHP.
Ensure responsible areas are compliant with all service level agreements, regulatory requirements, contractual requirements and accreditation bodies and that policies & procedures accurately reflect the current guidance and regulations.
Establish and maintain quantitative and qualitative performance standards and workload metrics for caregivers in addition to tracking and providing timely reports for caregivers and leadership as needed.
Work with peers on new products, benefit changes, and new lines of business in order to establish service team coverage as well as the necessary system changes.
Routinely review and re-enginee! r operations through continuous quality improvement as needed to meet demands.
Health Care Services Expert, ability to deliver affordable healthcare by applying stratification and impactful interventions; combining medical management, care management, community partners, delivery systems, and regulatory requirements to meet the needs of our population
- Graduate from an accredited school of nursing or graduate from an accredited equivalent clinical program
- Bachelor degree in Nursing or other clinical field
- Formal education or training in supervision, management, or leadership
- 2+ years in direct management or supervisory experience in a clinical or managed care setting
- 3+ years of clinical experience
- 2+ years utilization, quality or care management experience in an insurance or managed care setting
- Demonstrated experience in program planning, development and evaluation
- Currently licensed as a registered nurse in good standing in Oregon or must be willing to get registered in Oregon
- Master degree in Nursing, or related field
-Certification in case management, utilization management or quality improvement
- Project management, Six Sigma, Lean, Change Acceleration Process (CAP) experience or certification
- Experience with HEDIS, CAHPS, Medicare 5-Star Rating, NCQA and/or URAC accreditation