RN license for state of California required.
Position Purpose: Manages the care management team and the care management of members to develop and assess high quality, cost-effective healthcare outcomes. Manages escalations and care management issues related to members or providers.
- Oversees and reviews care management required documentation to maintain compliance with federal and state regulations and contractual agreements
- Contributes to the development and implementation of policies and procedures within the care management team based on regulatory requirements and industry standards
- May direct the daily activities of care management staff including reviewing and approving the caseloads based on state requirements, care management staff experience, and member needs
- Manages processes for escalation and/or complex cases, and provides guidance to team members to address member needs
- May manage or coordinate resolutions of member escalations and/or complaints and assists in audits and evaluations related to care programs and member concerns
- Contributes to the development, implementation, and oversight of care management programs to facilitate the use of appropriate services and resources
- May perform telephonic, digital, home and/or other site outreach to assess member needs and collaborate with resources
- Sets goals and objectives for care management team and oversees care management data and reporting metrics to achieve quality and cost-effective healthcare results and works with senior leadership, as required
- Monitors audits within care management to ensure compliance with regulatory requirements for federal, state, and National Committee for Quality Assurance (NCQA) standards, as required
- Provides feedback to care management team to improve member and provider experience and high-quality care
- Educates and provides resources for care management team on key initiatives and member outreach to facilitate on-going communication between care management team, members, and providers
- Assists care management senior leadership with onboarding, hiring, and training care management team members
- Leads and champions change within scope of responsibility
- Performs other duties as assigned
- Complies with all policies and standards
Education/Experience: Requires Graduate from an Accredited School or Nursing or a Bachelor's degree and 5+ years of related experience.
*Prefer UM and CM experience.
License/Certification:
- RN - Registered Nurse - State Licensure and/or Compact State Licensure required
*Must be licensed in California.
Location: Position is remote. Will work PST hours.
Pay Range: $102,900.00 - $190,500.00 per year
