Senior Manager Clinical Eligibility

HealthFirst•Herminie, PA

About The Position

The Senior Mgr of Clinical Eligibility will have knowledge of the current assessment process, for both Medicaid and Medicare programs. This position will support the Assessment Managers in planning, directing, and implementing processes for successful outcomes and achieving goals. The Sr Mgr conducts and contributes to member and family education regarding health management and community resources to enhance population health. This position will be responsible for the overall administration, development, and operation of the Assessment team. The Sr Mgr of Clinical Eligibility will function as a facilitator for the team and managers to ensure smooth workflow, efficiency and success within the four programs: PHSP, CC, AE, and SHP. Functions as a liaison to ensure process coordination with different organizational departments such as Intake/Medical Records/CMT/IT/HR/Marketing.

Requirements

NYS licensed RN
Bachelor’s degree
Intermediate Microsoft Word, Excel, Outlook, Powerpoint, Access, Adobe, Visio, and project skills
Proficient navigating internet browsers, computer hardware, and multiple applications simultaneously, using encryption security tools, multiple electronic PHI databases, working in with a VPN and Citrix platform and very accurate typing skills.
Demonstrated professionalism and leadership skills along with the ability to develop, direct, and support staff
Experience in home care environment, acute, sub-acute or long term care (LTC) setting or managed-long term care (MLTCP).
Experience in one of these areas: managed care organization, PACE, MLTCP, CHHA, licensed agency or a Lombardi program.
Excellent communication, time management, writing, critical thinking, and problem solving skills.
Supervisory, training, or management experience.

Nice To Haves

Knowledgeable of state and federal regulations including experience interpreting those regulations as it pertains to different programs.
Excellent interpersonal skills, especially relating well with a frail adult population, their families and community care providers, along with demonstrated ability to handle rapidly changing crisis situations while still achieving department goals and objectives.
Understanding of and sensitivity to cultural differences and needs of the community are essential with a diverse and multi-cultural work environment and community of members such as Spanish, Chinese, Russian, Creole and Korean.
Language preferences - Spanish, Russian, French, Creole, Mandarin, Cantonese

Responsibilities

Participates in all aspects of personnel management to ensure appropriate staffing, orientation, support, discipline, and timely performance appraisals.
Meets regularly with direct reports to review goals, trends, and performance measures and to facilitate change.
Participates in continued staff development to improve the decision-making process.
Provides administrative on-call coverage to troubleshoot and coordinate the delivery of care and services to members.
Manages Assessment Managers to ensure timely assessments and targeted interventions to meet a member’s changing condition(s).
Supports the care management teams to ensure effective care management and oversight of home vendor services.
Supervises and directs the completion of assessments at established intervals to coincide with care plan development/revision and ensures early identification and action to address emergent issues.
Assists members and prospective members with assessment and clinical eligibility questions.
Coordinates with contract services to ensure understanding of the MLTC model, FIDA, MAP, and MMCP and cooperation with the assessment process.
Ensures coordination with home health, nursing, and social work care as it relates to the care plan.
Facilitates problem solving by coordinating case conferences and investigations with the care teams.
Function as a facilitator for the team and managers to ensure smooth workflow, efficiency and success within the four programs: PHSP, CC, AE, and SHP.
Functions as a liaison to ensure process coordination with different organizational departments such as Intake/Medical Records/CMT/IT/HR/Marketing.
Additional duties as assigned.
Overseeing compliance with SHP standards and time frames for care planning and other recurring activities in accordance with established guidelines and DOH regulations.
Collaborating with the Department of Clinical Excellence (DOCE), coordinate orientation and in-service programs to meet regulatory requirements and support performance improvement.