Dignity Health Medical Foundation, established in 1993, is a California nonprofit public benefit corporation with care centers throughout California. Dignity Health Medical Foundation is an affiliate of Dignity Health - one of the largest health systems in the nation - with hospitals and care centers in California, Arizona and Nevada. Today, Dignity Health Medical Foundation works hand-in-hand with physicians and providers throughout California to provide comprehensive health care services to the many communities we serve. As Dignity Health Medical Foundation continues to grow and establish new premier care centers, we provide increasing support and investment in the latest technologies, finest physicians and state-of-the-art medical facilities. We strive to create purposeful work settings where staff can provide great care, while advancing in knowledge and experience through challenging work assignments and stimulating relationships. Our staff is well-trained and highly skilled, qualities that are vital to maintaining excellence in care and service.
Dignity Health Medical Group – Northridge Family Medicine, a service of Dignity Health Medical Foundation, is conveniently located on the Northridge Hospital Medical Center campus and offers full service family medicine, hospital medicine, maternity care, sports medicine, and pediatric services to the community. In addition to more than 10 family medicine providers, we are part of one of the few teaching hospitals in the valley, where the Dignity Health Family Medicine Residency at Northridge (affiliated with the David Geffen School of Medicine at UCLA) has educated family physicians for more than three decades, many of whom stay to serve this community.
The Manager of Care Management is responsible for managing the day to day operation of the Care Management Department including hiring, scheduling, coaching, development and evaluation of employee performance. Analysis of available data to measure individual and team performance, clinical program performance, team processes and compliance are essential. Working with staff, the manager will anticipate and resolve complex issues to ensure accurate, cost effective operations and the achievement of productivity and quality metrics. Additionally, the Manager will work in conjunction with the Director of Managed Care on a variety of critical tasks including the management of one or more focused clinical initiatives and representing the company externally in presentations with key provider and payer groups.
This position has oversight responsibility to plan, develop, and direct the Care Management Department; Develops and implements effective and efficient standards, protocols and processes; department decision support systems; and reports benchmarks which support continual enhancement of Care Management functions and promote quality health care for members.
Responsibilities may include:
- Coaches and provides feedback to associates regarding goal setting, work performance and performance management. Initiates action on staffing and performance reviews.
- Assists the Director in development of, and managing, the department budget.
- Manages all operational and management activities of the CM programs including the development and implementation of effective metrics to monitor productivity, composition of program descriptions and development of workflows and job aids, and management of clinical and non-clinical staff, as well as facilitation of team meetings.
- Reviews Care Management (CM) policies and procedures to ensure they are meeting regulatory requirements (NCQA) and are an accurate reflection of current CM practice eligibility, benefits and contracts.
- Conducts retrospective clinical review of CM documentation for appropriateness, completeness and timeliness.
- Acts as a clinical resource for Care Management Team.
- Facilitates continuity and coordination of medical care and services for new enrollees and members transitioning providers while in the middle of care.
- Facilitates the benefit interpretation request process by reviewing and researching all requests for any service, procedure or regulatory requirement that requires clarification and/or consistency in decision-making regarding appropriateness for coverage.
- Assists with the development of policies, procedures, and prior authorization guidelines.
- Responsible for achievement of team initiatives for medical cost management and payer delegation, in addition to the accuracy and effectiveness of care management processes and collaborating with the appropriate departments to improve their understanding of how these standards impact their departments.
- Collaborates with the Medical Director in determining medical necessity of service, level of care and appropriateness of care in the most cost effective, quality setting, as appropriate.
- Acts as a liaison to Legal, Compliance and Quality Department on those issues that have both legal risk and compliance aspects and coordinates with health plans, also being responsible for all corrective actions in assigned area.
- Works closely with all appropriate internal departments on issues related to utilization management and partnering for clinical presentations for provider and member groups.
- Identify 'wellness continuum' opportunities and develop successful blending of case, disease and medical management functions
- Performs other duties as assigned.
- Five (5) years' experience in case management; Two (2) years' management experience
- BSN/BS/BA and/or Masters Degree in Healthcare related field.
- Clear and current CA RN license.
- Basic level skills utilizing Microsoft Word, Excel and PowerPoint
- Leadership experience and skills
- Ability to be a Change agent
- Decision making/problem solving skills
- Clinical data analysis and trending skills Critical and ‘systems' thinker
- Excellent communication skills (verbal and written); Considerable interpersonal skills.
- Management skills (Human capital and project management)
- Ability to work independently and within a team environment
- Attention to detail
- Understanding of predictive modeling process/tools
- Training/teaching skills
- Strategic management skills
- Negotiation skills/experience
- Politically astute
- Proper grammar usage, phone etiquette and technical writing skills
- Time management skills
- Customer service oriented
- 1-3 years RN experience in an outpatient environment preferred. 3+ years RN experience in an outpatient environment strongly preferred.
- Experience with quality metrics/markers preferred.
- Pharmacy/medication knowledge preferred.
- Experience in Disease Management preferred
- Experience in Medicaid and/or other Government programs (Aged, Blind and Disabled, Medicare etc.) preferred.
- Experience in Medicaid MCO preferred.
- Multiple years prior supervisory skills preferred.
- Managed Care, Utilization management, Case Management and/or Quality Improvement certification preferred.
- Intermediate Microsoft Office skills preferred.
- Internet research skills preferred.
- Knowledge of trends in healthcare, managed care, Medicaid, case management, medical management and quality improvement.
Keywords: outpatient, clinic, ambulatory, medical foundation, quality metrics, quality markers, prior authorization, care coordination, nurse shift manager, nurse, RN, registered nurse, staff nurse, leadership, lead, supervisor, manager, management, case management, utilization review, utilization management
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