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

• Manage and triage self-referrals.
• Identify high risk members through HRA, reporting and admissions data.
• Audit patient charts of delegated case management programs to meet accreditation standards.
• Connect members with in-network providers and resources.
• Participate in activities related to care management program build, implementation, oversight, and delegation.
• Perform utilization management reviews as needed according to accepted and established criteria, as well as other clinical guidelines and policies.
• Assist members in understanding their available medical benefits and connecting them with in network providers and community resources.
• Identify barriers preventing the member from meeting maximum quality of life.
• Review and Evaluate Health Risk Assessment (HRA) data to help drive development of programs and services geared toward member needs.
• Review and Evaluate member outcomes data and work with other team members on performance improvement opportunities.
• Utilize NCQA standards in auditing processes of member records as part of care management oversight processes.
• Investigate potential quality of care issues that may affect the quality or safety of the health of members.
• May review medical records and other documentation to ensure quality care.
• Assist in reviewing and updating activities and resources to address member needs.
• Participate in case management and quality committees.
• Assist in reviewing and updating policies and procedures to align with delegated processes.
• Assist in quarterly reporting of delegated case management processes to meet accreditation standards.
• Assist in submission of required documents/policies during application process to accrediting body.

What This Job Offers

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