RN Manager of Delegation Compliance

CVS Health•Work At Home-Illinois, IL

4d•$88,374 - $190,344•Remote

About The Position

This position is responsible for a range of activities supporting delegated Care Management and Utilization Management functions. These may include, but are not limited to, responsibility for implementation of new delegated functions, including project planning, system readiness, accountability for reporting requirements, hiring, training, and internal/external communication required for launch. The Manager ensures departmental adherence to program standards, ensures the care programs meet compliance requirements and metrics as set by the health plan and CMS, provides initial and ongoing education to staff, and serves as the liaison between OSH and insurance providers, other business partners, vendors and internal stakeholders as required.

Requirements

Bachelor’s in Nursing
Active RN license within one or more OSH states
Willingness to obtain cross-state licensure, as needed
5+ years of healthcare experience, preferably in a primary care and/or managed care setting
2+ years direct supervisory experience
Certified Case Manager (CCM) or equivalent case management certification required, or willingness to obtain within 12 months of hire
Knowledge of Medicare/Medicaid and NCQA requirements
Practical and operational experience in a managed care environment, preferably with working knowledge of related legal/regulatory/health plan requirements
Demonstrated experience leading teams, competence with change management, and leading process improvement
Knowledge relating to healthcare delivery workflows, project management, and quality improvement is required
Prior experience in a similar role at an IPA, Health Plan or MSO will be advantageous
Strong teamwork and interpersonal skills. Must be able to work effectively with cross functional groups, fostering teamwork with a commitment to quality
Passion for excellence, willing to go the extra mile to achieve objectives and ensure consistently high quality work product
Ability to succinctly summarize and synthesize large amounts of information
Quick learner comfortable with a high level of ambiguity
Strong accountability and discipline against timelines and deliverables
Strong clinical and assessment skills
Outstanding verbal and written communication skills
Ability to work independently and maintain flexibility in a fast-paced, start-up environment
Self-starter with a high level of accountability and responsibility for the outcome of care
Highly organized and able to manage multiple priorities appropriately
Independent problem-solving skills
Able to work collaboratively and build enduring relationships with providers, patients and the multidisciplinary team.
A flexible, positive attitude
Proficient with Microsoft Office, Google Suite, and healthcare EMRs
US work authorization
Someone who embodies being “Oaky”

Responsibilities

Oversee compliance for UM and CM to deliver an unmatched patient experience and ensure delegation compliance.
Audit individual charts according to QA Audit Protocols to ensure compliance with program responsibilities and best practices
Possess knowledge of contractual, accreditation, federal and business requirements for assigned program and ensure compliance with program requirements and develop corrective action plans as needed
Establish work procedures and processes that support the company and departmental standards, procedures and strategic directives
Establish workflows that meet compliance requirements and align with organization-wide clinical protocols
Lead the review of policies and procedures, program descriptions, and evaluations; Conduct training for new team members and other internal parties as required
Provide statistical and performance feedback, and coaching on a regular basis to each team member in their assigned region
Create and maintain a high-quality work environment so team members are motivated to perform at their highest level
Provide continual evaluation of processes and procedures. Responsible for suggesting methods to improve area operations, efficiency, and service to both internal and external staff
Collaborate with other OSH program leaders to implement initiatives in support of integrating delegated services with core OSH care model (e.g. care team, social work, behavioral health, utilization management, patient engagement, central telehealth, etc.) to promote patient outreach and engagement and identify and address patient needs.
Serve as point of contact for / management of health plan relationships related to delegated care management
Oversight of delegated entities and internal operating partners servicing Care Coordination, including management of operational performance and program execution
In partnership with Business Intelligence, set, implement and monitor system configuration requirements in accordance with operational and regulatory specifications required for new programs
Complete report submissions, including validation where needed
Other duties as assigned