Manager, Case Management (Commercial Line of Business)

Case Management Program Manager

This position serves as the expert and leader for case management activities and overall coordination within the Case Management Program and the Health Plan. This position oversees the clinical and administrative operations and implementation of Case Management activities, including systematic approaches to improve member health status, and expectations set forth by regulatory and accrediting entities including NYS DOH (OMH, OASAS, OCFS), CMS, NCQA and BlueCross BlueShield Association (BCBSA) for the Federal Employee Program (FEP). The Manager serves as a resource to management, internal staff, regulatory and accrediting agencies, members and providers by conducting research, responding to inquiries and resolving issues.

Essential Accountabilities :

Responsible for direction and supervision of daily activities of the Case Management staff, establishing a foundation for strong teamwork and customer service; provides ongoing staff development and assures adequate staffing to accomplish corporate goals.

Participates in recruitment, training, and retention of staff. This includes initial and periodic license verification when applicable.

Maintains employee files with updated annual performance reviews, professional and mandatory education, and annual statements with signature.

Instructs and acts as a resource for staff in dealing with special situations or problems.

Conducts periodic case reviews, employee performance reviews, and staffing patterns, identifying areas needing improvement and initiates appropriate action including productivity monitoring and inter-rater reliability.

Coordinates regular team meetings with staff.

Ensures staff compliance with all regulatory and accrediting standards. Keeps abreast of changes and responsible for implementation and monitoring of requirements.

Responsible for the clinical and administrative operations and implementation of all Case Management outreach and engagement interventions to members.

Provides appropriate resources and assistance to staff with regards to managing cases per national professional standards, as well as other regulatory bodies.

Provides updated information to training team and staff related to appropriate professional educational resources and serves as an information source for the department.

Maintains expert knowledge of current member program activities and serves as a resource for the implementation and training teams in support of new program development and / or initiatives.

Participates in the development and review of policies and procedures which support clinical and operational program operations.

Ensures operational processes are implemented consistently per department policies, procedures and guidelines. Facilitates quality, cost effective medical and benefits management and monitors results of the programs through outcome indicators.

Identifies strategies to improve health care resource management and communicates to internal and external customers.

Regularly monitors effectiveness measures such as productivity metrics, satisfaction survey results, and member complaints.

Conducts data collection and reporting for member program quality committees.

Serves the quality committees by attending meetings, making recommendations to leadership regarding corrective action plans, and conducting other quality activities as directed.

Facilitates interdepartmental coordination and communication to ensure delivery of consistent and quality health care services.

Maintains documentation relative to the activities of the department and prepares reports as necessary, including those related to Quality Improvement Plan activities. Provides presentations as they relate to specific functions of area supervised.

Responsible for overall compliance and all regulatory and accrediting standards including NYS DOH, CMS, FEP and NCQA formal accreditation activities. Keeps abreast of changes and responsible for implementation and monitoring of requirements.

Performs on-going program evaluation for effectiveness and value, and is responsible for providing ongoing input to department, division and corporate leadership as to the effectiveness of the CM programs as well as identification of opportunity for enhancements to those programs for the benefit of our members and our company.

Assists in implementing and monitoring departmental changes and initiatives necessary to accomplish corporate goals.

Works in conjunction with Case Management Director and other department managers to respond to employer group requests for information and requests for proposals related to Case Management services.

Works in conjunction with operations and data & analytics teams to develop ongoing tracking systems, outcome driven data reporting, and related finance department liaison for consultative purposes to obtain highly complex data and reports, as necessary.

Responsible for design and oversight for overall program metric and performance reporting in collaboration with the Director, including summary and communication to staff and senior management.

Responsible for all regulatory reporting to ensure accurate and timely data is submitted to meet requirements.

Keeps designated management aware of progress toward goals and productivity.

Accepts responsibility for personal professional education requirements per departmental policy.

Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies' mission and values, adhering to the Corporate Code of Conduct, and leading to the Lifetime Way values and beliefs.

Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.

Maintains knowledge of all relevant legislative and regulatory mandates and ensures that all activities are compliant with these requirements.

Conducts periodic staff meetings to include timely distribution and education related to departmental and Ethics / Compliance information.

Performs other duties and functions as assigned by management.

Minimum Qualifications :

One of the following current New York State clinical licensures is required : RN, PT, BH Clinician, NP, PA, or Registered Dietician.

Minimum of eight (8) years of relevant experience required.

Minimum of four (4) years previous Management experience required.

For Long Term Services & Supports (LTSS) role, a minimum of 2 years LTSS experience preferred.

Must possess strong leadership skills, excellent written and verbal communication skills, project management and organizational skills, problem solving and analytical skills, ability to make decisions using solid judgment to impact identified problems, and the ability to work effectively with all levels of personnel in the health care industry.

Strong working knowledge of Managed Care Industry, Corporate Medical Policies, NCQA standards, HEDIS, CMS requirements, NYSDOH medical management mandates & program requirements and / or Blue Cross Blue Shield (BCBS) FEP programs.

Reads, analyzes, and understands data and reporting. Ensures accuracy of data.

Ability to make presentations and interact professionally with internal management, employer groups, medical directors, providers and community agencies.

Maintains all confidentiality policies and procedures according to established guidelines.

Ability to multitask and balance priorities.

Demonstrated leadership skills with the ability to problem solve and effectively communicate.

Ability to work independently.

Must demonstrate proficient experience in use of a computer. Example-creating documents, Word, Excel, Internet and email.

Excellent written and verbal communication skills and organization skills required.

FEP Specific Qualification :

For incumbents aligned to the Federal Employee Program (FEP) line of business, Case Management Certification required within three (3) years of either hire and / or moving into this role supporting the FEP LOB.

Physical Requirements :

Ability to travel across the Health Plan service region for meetings and / or trainings as needed.

Ability to work prolonged periods sitting and / or standing at a workstation and working on a computer.

Ability to work while sitting and / or standing at a workstation viewing a computer and using a keyboard, mouse and / or phone for three (3) or more hours at a time.

Ability to work in a home office for continuous periods of time for business continuity.

Must be able to work beyond normal work hours and respond to changing needs on short notice.