Manager, Care Management (RN) - Maternal Child Health

Centene Corporation•Newark, DE

1d•Hybrid

About The Position

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. This is a remote role with occasional in office engagement, and attending required meetings with the state. 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.

Requirements

Graduate from an Accredited School or Nursing or a Bachelor's degree and 5+ years of related experience.
RN - Registered Nurse - State Licensure and/or Compact State Licensure required.

Responsibilities

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.