Peak Care Manager

WVU Medicine

122d

About The Position

Welcome! We’re excited you’re considering an opportunity with us! To apply to this position and be considered, click the Apply button located above this message and complete the application in full. Below, you’ll find other important information about this position. Reporting to Manager of Care Management, the Care Manager will be an integral member of the health plan’s medical management team. This position is responsible for identifying and connecting high risk members to appropriate resources and programs to achieve optimal quality and financial outcomes.

Requirements

• Current unencumbered licensure with the WV Board of Registered Nurse Professional Nurses, or appropriate state board where services will be provided, as a Registered Nurse professional OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC).
• Three (3) years of healthcare clinical experience.

Nice To Haves

• Bachelor's Degree in Nursing OR Associate of Science in Nursing Degree (ASN) or Diploma; Currently enrolled in a BSN program and BSN completion within three (3) years of hire.
• Management of Medicare and/or Medicaid populations preferred.
• Two (2) years Care Management experience.

Responsibilities

• Managing and triaging self-referrals.
• Identifying high risk members through HRA, reporting and admissions data.
• Auditing patient charts of delegated case management programs to meet accreditation standards.
• Connecting members with in-network providers and resources.
• Participating in activities related to care management program build, implementation, oversight, and delegation.
• Performing utilization management reviews as needed according to accepted and established criteria.
• Assisting members in understanding their available medical benefits and connecting them with in network providers and community resources.
• Identifying barriers preventing the member from meeting maximum quality of life.
• Reviewing and evaluating Health Risk Assessment (HRA) data to help drive development of programs and services geared toward member needs.
• Reviewing and evaluating member outcomes data and working with other team members on performance improvement opportunities.
• Utilizing NCQA standards in auditing processes of member records as part of care management oversight processes.
• Investigating potential quality of care issues that may affect the quality or safety of the health of members.
• Reviewing medical records and other documentation to ensure quality care.
• Assisting in reviewing and updating activities and resources to address member needs.
• Participating in case management and quality committees.
• Assisting in reviewing and updating policies and procedures to align with delegated processes.
• Assisting in quarterly reporting of delegated case management processes to meet accreditation standards.
• Assisting in submission of required documents/policies during application process to accrediting body.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Bachelor's degree
• Number of Employees: 5,001-10,000 employees