Senior Manager of Clinical Operations

Company: Elderwood Health Plan
Location: Grand Island
Posted on: June 25, 2022

Job Description:

Join Our Team: Put the CARE back in CAREER - Join our team today! Overview:Join a company that cares for YOU!
Our Excellent, Competitive Compensation, and a Full Benefit Package includes:

• Up and Coming downtown location with FREE PARKING!
• Competitive wages and opportunities for advancement
• Medical, Dental, Vision Insurance
• Life insurance
• 401(k) with matching
• Paid Holidays
• Generous Paid Time OffSummary:
  The Senior Manager Clinical Operations interfaces directly with the Care Services Manager (Social Work/Member Services) and RN Care Managers to ensure timely assessment and coordination of appropriate levels of care for delivery of patient centric comprehensive services to Elderwood Health Plan members within the MLTC benefit structure through leadership and oversight to the Utilization Management team and external provider collaboration. The Senior Manager of Clinical Operations also works closely with the Director and Medical Director specific to forward strategic clinical planning applicable to sustainable expansion and growth of the health plan. This individual is a core member of the QAPI work group to conduct research and development activities applicable to both service area and product expansion efforts.Employee Perks!: 401K Retirement Plan with Company Match, Clean, Neat & Newly Renovated Facility, Close to thruway entrances/exits, Consistent work and holiday rotations to provide you with a great work/life balance, Employee of the Month recognition, Enjoy a fun and diverse work environment, Enjoy being a part of a strong and diverse team, Free On-Site Parking, Generous PTO & holiday package, Life Insurance, Medical, Dental, and Vision insurance, Point-earning employee reward program: redeem for prizes!, Strong leadership, Truly make a difference in our residents' lives while providing top notch care Responsibilities:
  • Provides direct oversight of the Utilization Management Team, managing all daily processes in totality impacting Risk and NFLOC scores in accordance with regulatory requirements and internal Elderwood
  • Ensures timely escalation and visibility specific to need for appropriately licensed and knowledgeable staffing and/or resources necessary to effectively conduct care management nursing functions across plan population for finance
  • Responsible for full cycle talent acquisition process and decision-making of Utilization Management staff to include, but not limited to job posts, interviewing,
  • Responsible for staff performance evaluations, administering discipline, training and/or
  • Responsible for scheduling, approving timecards and processing payroll for direct
  • Ensures appropriate training and education is provided for UM onboarding, new process, and remedial
  • Ensures all UM focused care management activities are performed in accordance with contractual requirements, state policy, and plan
  • Ensures plan emergency management policy and procedure remains intact with appropriate staff training and oversight/external provider collaboration for high risk
  • Monitors the effectiveness of existing procedures and outreach/intervention efforts in demonstrating positive outcomes for members and high satisfaction for participating
  • Ensures appropriate case planning, education and interventions are conducted for members in accordance to risk level and acuity of
  • Ensures exchange of information between plan and behavioral health/medical/ancillary providers in recommending and obtaining effective interventions for comprehensive care plans for at-risk members.
  • Reviews and evaluates all requests for internal plan appeal, and Fair Hearing if required, with determination and notification requirements according to policy and regulatory guidelines.
  • In response to performance data, addresses key care management outcomes and implements UM improvement activities to maximize ability for closure of service gaps and achieve timely resolution for identified member needs.
  • Ensures timely and effective coordination of care specific to CHHA requests/referrals between internal team and external vendors; provides regular updates.
  • Actively participates in strategic planning and competitive intelligence specific to enhancement of care management functional processes and build of required infrastructure for benefit administration/ utilization review, provider oversight and collaboratives such as VBP and expansion efforts.
  • Provides training to team and address any gaps in policies and procedure that are identified.
  • In participation with the QAPI Work Group, establishes guidelines for safe and appropriate care planning as well as benefit administration/utilization management practices that meet all plan and regulatory requirements.
  • Ensures efficient management of assignments, competency and educational needs of the UM team and effectively coordinates and controls resources.
  • Monitors performance against defined operational metrics and establishes mechanisms for reporting on nursing care management indicators.
  • Performs routine regulatory monitoring of nursing functions and coordinates/participates in external quality and audit activities.
  • Actively collaborates with Care Services Manager in the discharge planning process with direct nursing clinical recommendations with the facility discharge planner to ensure timely discharge, appropriate follow up and continuity of care.
  • Escalates cases with quality of care concerns to director to arrange for team review and resolution. Protects member rights at all times.
  • Remains flexible and responsive to changes in schedule, workload or focus and champions a culture of excellence.
  • Travels to off-site meetings as directed, arrives to work on time, regularly, and works as scheduled.
  • Recognizes and follows the dress code of the facility including wearing name tag at all times.
  • Follows policy and procedure regarding all electronic devices, computers, tablets, etc.
  • Supports and abides by EHP's Mission, Vision, and Values.
  • Abides by EHP's businesses code of conduct, compliance and HIPAA policies.
  • Performs other duties as assigned by supervisor, management staff or Administrator.Base salary starting at (note: salary increases with experience):: USD $82,000.00/Yr. Qualifications:
    • Minimum of bachelor's degree in nursing (BSN); Master's in Nursing or equivalent preferred
    • Minimum of 8 years of clinical nursing experience with at risk populations in home care, case management, utilization review, discharge planning or managed care
    • Recent experience as a lead in a functional area, managing cross functional projects (i.e. Change Management, payment reform/DSRIP/VBP), and supervisory experience including hiring, training, assigning work and managing the performance of team
      
      • Recent experience working as a supervisor performing case and/or utilization management functions, with thorough knowledge in assessment, diagnosis, treatment approach for individuals with medical/behavioral conditions, case management methodology, mental health community resources and local health delivery systems
        
        • Demonstrated computer skills with Microsoft Office,electronic medical records, web-based programs and external coordination sites applicable to position (i.e. UAS-NY, RHIO)
          
          • Current, valid driver license
          • In good standing with and demonstrated knowledge of Medicare and Medicaid programs
          • Demonstrated proficiency in HIPAA Privacy and Security compliance
          • Bilingual Spanish speaking skills preferred

Keywords: Elderwood Health Plan, Buffalo , Senior Manager of Clinical Operations, Executive , Grand Island, New York