Responsible for assisting with implementation, integration and operational direction of the case management - Special Needs program within MedStar Family Choice, District of Columbia (MFC-DC) through organizing, directing, assessing and evaluating a clinical system that manages cost and quality patient care outcomes. Leads the continuum of care and work collaboratively with interdisciplinary staff, both internal and external to the organization to facilitate the continuum of care, through education and advocacy to enhance health outcomes. Manages a team of Case Managers including RNs and Social Workers to coordinate, negotiate, procure and manage care of Enrollees to facilitate cost effective care and patient satisfaction.
We recruit, retain, and advance associates with diverse backgrounds, skills, and talents equitably at all levels.
Education- Bachelor's degree in related field required
Experience- 3-4 years Case management experience and 3 years diverse clinical experience required and
- 1-2 years 2 years supervisory experience preferred
Licenses and Certifications- Valid RN license in the District of Columbia. required and
- Active CCM (Certified Case Manager) or CCM within 1-1/2 Yrs required
Knowledge, Skills, and Abilities- Excellent verbal and written communication skills.
- Ability to follow verbal and written instructions.
- Proficient with Microsoft Office applications especially Word, Excel and PowerPoint.
- Ability to enter and retrieve information using a PC.
- Working knowledge of various computer software applications.
- Knowledge of current trends in health care delivery and population management.
- Knowledge of NCQA, HEDIS, InterQual and local regulatory guidelines preferred.
Acts as a liaison between IS/IT and the clinical team to identify workflow / system issues and resolutions. Uses technology to enhance decision making and effectiveness.Assists staff with setting personal and educational goals and objectives to enhance their professional development. Develops and implements education programs to coordinate staff development and training needs both for software and clinical training issues.Assists with identifying and development of department goals, objectives, policies, procedures, performance and quality/safety and productivity standards in collaboration with the Director. Ensures compliance with policies and procedures and governmental and accreditation regulations.Conducts monitoring of compliance of Special Needs, Case Management, Disease Management and Utilization Review standards, as per MFC policies and procedures.Develops and maintains a working relationship with applicable staff at the Department of Healthcare Finance and Community Agencies. Complies with governmental and accreditation regulations.Demonstrates behavior consistent with MedStar Health mission, vision, goals, objectives and patient care philosophy.Demonstrates skill and flexibility in providing coverage for staff.Empowers case managers to act as an advocate while assisting enrollees/members to coordinate and gain access to medical, behavioral, psychosocial and other essential services to meet their healthcare needs.Identifies and researches case management issues that impact enrollee/members care. Reports review findings to Director of Clinical Operations and Medical Director when appropriate.Leads staff meetings, work groups etc., as assigned. Addresses issues impacting MFC with community agencies and providers. Delivers updated information back to department staff.Maintains current knowledge about and acts in accordance with procedures regarding enrollee/member confidentiality, principles of consent and Advanced Directives.Maintains current knowledge of benefits, claims, eligibility, enrollment and authorization in order to accurately respond to questions and coordinate enrollee/provider services.Monitors telephone coverage and processes related to enrollee/ provider questions.Educates staff regarding documentation compliance and implements corrective action plans when necessary.Participates in multi-disciplinary quality and service improvement team meetings and on committees and represents the department and organization in community outreach efforts.Performs other duties as assigned.Provides backup support to Director as required. Works in partnership with the Manager of Case Management and Manager of Utilization Management in development of the annual Clinical Operations Plan and the Clinical Operations Appraisal.Provides ongoing individual coaching and support to staff and acts as a resource for clinical, social, utilization and appeal review issues as they relate to case management. Meets regularly with department staff to enhance communication and facilitate implementation and progress toward program objectives.Selects, trains, orients and assigns department staff. Assists with the development of performance standards, evaluates performance, and conducts performance management planning. Initiates or makes recommendations for personnel actions. Maintains ongoing communication with subordinates to review progress, provide feedback, discuss new developments, and exchange information.Serves as a first line intermediary in inter-associate disagreements; knowing when to escalate issues to the next level of management. Provides oversight and strategic direction for the case management team while providing mentorship, leadership, direction and support.
