Manager, SNF Case Management

Regal Medical Group•Los Angeles, CA

7d•$120,000 - $130,000•Onsite

About The Position

The Manager of SNF Case Management is responsible for actively participating in the review process of pre-service requests for services, and to follow guidelines in the approval of those services or in making recommendations for other determinations to the provider/vendor (denial/modification/redirection). The goal of the Manager of SNF Case Management will support the other medical directors of the UM team by collaborating in processes and procedures, while working with the team to deliver excellent care in a cost-effective manner based on medical management referral processing guidelines. The Manager of SNF Case Management will be detail-oriented and able to research and successfully evaluate often-complex clinical information to help formulate decisions and communication with members, providers and internal users. Additionally, the Manager of SNF Case Management will work with medical management and network management teams to establish, develop, and maintain IPA provider relations via in-person meetings, formal and informal provider education, communication, and delivery of management services.

Requirements

Previous management experience required.
Must have experience in managing high risk cases.
Experience with SNF Case Management.
High level knowledge of Case Management processes and principles.
Must have excellent verbal and written communications skills.
Must have excellent organizational skills.
Must have prior experience with project/program development and implementation.
Must have working knowledge of MS Office environment.
Requires current CA driver’s license and car insurance.
Requires active CA RN license, CCM certification preferred.

Nice To Haves

Prior experience in managed care environment preferred.
CCM certification preferred.

Responsibilities

Manages and monitors Enrollees assigned to High Risk (Vital Care) case management programs to ensure efficient and timely delivery of care, timely referrals, and moving the Enrollee’s treatment plans through the care continuum.
Develops, monitors, and analyzes Program and Department reports and identifies trends to improve clinical and utilization and quality outcomes.
Collaborates with the RMG Medical Directors to analyze data and implement programs that will improve Enrollee outcomes.
Develop a standardized process for triaging and enrollment of appropriate members into High Risk (Vital Care) case management programs for RMG.
Identifies and develops Program and Department policies and procedures and ensures compliance and consistency throughout RMG regional sites.
Develops and coordinates Program and Department strategies for ensuring the delivery of care in the most cost effective setting.
Act as a resource for hospitalists, SNFs, outpatient utilization management staff, home health care agencies, Employer home-visit physicians and nurse practitioners.
Motivates, instructs, mentors, audits and leads and constantly improves the quality of service and clinical outcomes rendered by the Employer’s the High Risk (Vital Care) Case Management staff.
Develops annual Program and Department goals and objectives focused on improving patient outcomes and efficiency.
Implements tools and processes that direct and role model a high level of customer service behavior toward Enrollees.
Works collaboratively with the entire Medical Management team to ensure that Employer company goals as well as compliance with regulatory and health plan requirements are met.
Has direct oversight responsibility and accountability of the Program and Department case management and ancillary staff.
Has oversight of Vital Care Clinics.
Training, mentoring, auditing of the clinical competency, productivity, contribution, customer service interaction of Program and Department professional and non professional staff. Act as a resource to all staff members of the Program and Department.
Provide regular audit reports on Program and Department staff and action plans to improve efficiency and efficacy.
Assume on call responsibilities to support and act as a resource to Program and Department staff, and ensure the timely response to urgent/emergent Enrollee needs.
Directly report to Vice President of Utilization Management.
Manager’s service area jurisdiction and responsibilities may be expanded and/or changed at Employer’s discretion and in consultation with the Vice President of Utilization Management.
Other responsibilities to be determined by mutual agreement in consultation with the Vice President of Utilization Management.