Job Description:
Looking for a way to make an impact and help people?
Join PacificSource and help our members access quality, affordable care!
PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, national origin, sex, sexual orientation, gender identity or age.
Diversity and Inclusion: PacificSource values the diversity of the people we hire and serve. We are committed to creating a diverse environment and fostering a workplace in which individual differences are appreciated, respected and responded to in ways that fully develop and utilize each person's talents and strengths.
Manage the daily operations, including oversight/supervision of the Care Management Team which may include the following: Health Services Representatives (HSR) Member Support Specialists (MSS) and Nurse Case Managers (NCM) and Behavioral Health Clinicians involved in care coordination and case management functions. Key participant in Health Services (HS) strategy, program development and implementation. Integrally involved in, and accountable for, the success of the PacificSource Care Management program development and performance internal measures as well as those established by regulatory entities.
Essential Responsibilities:
- Work closely with the HS Director and other HS Managers to facilitate the development and implementation of new programs and processes to support ongoing success of department goals and initiatives, including but not limited to; ongoing activities related to physical and behavioral health integration and the development of a cohesive team approach to care management.
- Foster effective teamwork and performance. Manage change and encourage innovation. Build collaborative relationships, encourage involvement and initiative and develop goal orientation in others.
- Take a leadership role in initiation and implementation of departmental process/performance improvement activities Responsible for process improvement and working with other departments to improve interdepartmental processes. Utilize LEAN methodologies for continuous improvement. Utilize visual boards and frequent huddles to monitor key performance indicators and identify improvement opportunities.
- Serve as back-up for the Director of Care Management and Utilization Management Manager, as needed.
- Work collaboratively with the UM Director and Manager Team to develop, implement, and oversee the utilization management process to include; coordination of prior authorization needs for members engaged with care management, as well as the inpatient concurrent review process to ensure medical appropriateness, care coordination needs, and discharge planning for PacificSource patients who have been hospitalized.
- Develop and oversee the care management process to ensure care coordination and case management needs of PacificSource's are being met and their outcomes are being improved.
- Ensures consistent workflow and a comprehensive database of patients enrolled in care management and care coordination programs that allows for tracking of case loads, case management program success or failure, and patient and population outcomes.
- Ensure nurse case managers are providing timely notification of large cases to finance, underwriting, stop loss and other company leaders, as necessary.
- Serve as key driver and participant to ensure PacificSource care management programs are coordinated with the case management and care coordination functions of our provider and community partners.
- Responsible for oversight, management, development, implementation, and communication of HS case management and care coordination programs that coordinate and augment community partner programs.
- Oversee and monitor processes to ensure the protection of personal health information.
- Facilitate the provision of exceptional customer service to members, providers, employers, agents, and other external and internal customers. Ensure that the delivery of services meet acceptable standards and company and customer expectations.
- Monitor, evaluate, and report performance relating to volumes, quality, outcomes, accuracy, customer service, and other performance objectives.
- Serve as a liaison with all PacificSource departments to coordinate optimal provision of service and information.
- Serve as a resource and participate in development of policies, procedures, and operations.
- Collaborate and coordinate Health Services department staff between regional offices. At regional offices, represent Health Services by serving on management teams and support marketing and development initiatives towards achievement of PacificSource Health Plans goals specific to the region.
- Attend continuing education opportunities relevant to case management and care coordination to ensure that PacificSource care management programs maintain current best practices and implement innovative models of care.
- Maintain frequent and consistent department meetings and one-on-one meetings with individual contributors.
- Establish and monitor progress towards goals for care management programs, including case loads, outcomes, case timeliness, quality of interventions, training and physician outreach efforts.
- Encourage and support team members in their pursuit of case management and care coordination certifications.
- Responsible for hiring, staff development, coaching, performance reviews, corrective actions, and termination of employees. Provide feedback to direct reports, including regular one-on-ones and performance evaluations.
- Develop annual department budgets. Monitor spending versus the planned budgeted throughout the year and take corrective action where needed.
- Coordinate business activities by maintaining collaborative partnerships with key departments.
- Actively participate as a key team member in Manager/Supervisor meetings and HS Management meetings.
- Actively participate in various strategic and internal committees in order to disseminate information within the organization and represent company philosophy.
- Ensures ongoing monitoring and adherence to applicable state and federal regulatory and associated compliance requirements.
Supporting Responsibilities:
- Meet department and company performance and attendance expectations.
- Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
- Perform other duties as assigned.
SUCCESS PROFILE
Work Experience: 5 years clinical experience required. A minimum of 3 years direct health plan experience in case management, utilization management, or disease management, or equivalent preferred. Prior supervisory or management experience required.
Education, Certificates, Licenses: Registered Nurse or Licensed Clinical Social Worker or other licensed healthcare or behavioral health care clinician, Oregon licensure required. Certified Case Manager Certification (CCM) as accredited by CCMC (The Commission for Case Management) strongly desired at time of hire. CCM certification required within two years of hire.
Knowledge: Thorough knowledge and understanding of medical and behavioral health procedures, diagnoses, and treatment modalities, procedure codes, including ICD-9 & 10, DSM-IV & V, CPT codes, health insurance and State of Oregon mandated benefits. Knowledge of community services, providers, vendors and facilities available to assist members. Strong knowledge of health insurance; including managed care products as well as state mandated benefits. Ability to develop, review and evaluate utilization and care management reports. Experience in adult education preferred. Proficient in the use and implementation of the following tools and concepts across all teams within scope and accountability: Training, Coaching, Strategy Deployment, Daily Operations, Visual Management, Operational Improvement & Team Building/Development.
Competencies:
Building Trust
Building a Successful Team
Aligning Performance for Success
Building Partnerships
Customer Focus
Continuous Improvement
Decision Making
Facilitating Change
Leveraging Diversity
Driving for Results
Environment: Work inside in a general office setting with ergonomically configured equipment, as needed. Travel is required approximately 20% of the time.
Skills:
Accountable leadership, Collaboration, Communication, Data-driven & Analytical, Delegation, Listening (active), Situational Leadership, Strategic Thinking
Our Values
We live and breathe our values. In fact, our culture is driven by these seven core values which guide us in how we do business:
- We are committed to doing the right thing.
- We are one team working toward a common goal.
- We are each responsible for customer service.
- We practice open communication at all levels of the company to foster individual, team and company growth.
- We actively participate in efforts to improve our many communities-internally and externally.
- We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community.
- We encourage creativity, innovation, and the pursuit of excellence.
Physical Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.
Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.
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