Will effectively manage staff assigned to the After Hours Team and successfully enable provider's access to request preadmission, inform plan of emergent services into hospitals and/or provide discharge services after business hours. Serves as a resource for staff, providers and members as necessary.
The After Hours On-Call Manager provides the leadership, guidance and operational support needed for the After Hours Team to have on-going and measurable success. The focus is to maximize member outcomes and deliver a high level of provider and staff satisfaction while complying with all regulatory, accreditation and Peoples Health guidelines, policies and procedures. Additionally, the manager will develop and implement process improvement and project management activities needed to achieve medical management goals and objectives.
Document, measure, improve, manage and report the productivity, quality and regulatory compliance of clinical and administrative staff
Oversee the various medical necessity review, authorization, care coordination and redirection of members
Manage staff to ensure compliance with all Peoples Health Human Resources policies, including attendance, punctuality, leave, confidentiality, and other standards of conduct
Responsible for the ongoing training of staff including the familiarization of plan benefits, network design, provider contract requirements, medical necessity review, authorizations and claims payment processes including reports, policies and procedures, software applications, regulatory guidelines and education required to maintain staff credentials.
Assist the AVP of Medical Management Operations to ensure adequate staffing for the After Hours team, including the maintenance of job descriptions and task lists; interviewing, hiring, and training, evaluations and corrective actions; staff scheduling and various development activities
Coordinate with MedicalManagement Operations, Health Services and medical Affairs staff to maximize member outcomes; achieve a high level of member and provider satisfaction; including the continued achievement of URAC accreditation and targeted levels for relevant HEDIS measures
Plan, schedule, conduct and follow-up with meetings, in-services and other communications with management staff, project teams and work groups required to achieve Peoples Health medical management objectives
Contribute innovative, measurable process improvement ideas to facilitate and improve overall department functions
Development, implement and manage change, champion new initiatives and support/implement corporate priorities and policy decisions
Develop, maintain and manage authorization reports with Operations, IT, Decision Support, Compliance, Audit, Accreditation, Finance and other relevant Administrative staff
Review and comply with Peoples Health Standards of Conduct, HIPAA and all relevant Peoples Health policies and procedures, and all applicable local, state and Federal laws, regulations and guidelines
Develop and maintain expertise in Outlook, Word, Excel, Power-Point, Project, Access, Visio and other office management software applications needed to effectively communicate and manage both After Hours staff and processes
Reviews After Hours Activity Summary Log regularly to review work-flow and to ensure compliance with Peoples Health guidelines and policies
Bachelor's degree in Nursing required. Business Administration or Healthcare Administration, MSN, MBA or MHA highly preferred. Must have a minimum of 3 years experience in managed care, including utilization or quality management, health services, medical management or other related MCO departments/functions. In addition, minimum of 5 years experience in healthcare with at least 3 years experience as a Supervisor, Manager or Administrator. Excellent organizational skills required. Must be able to effectively interact with physicians, nurses and other clinical staff. Strong verbal and written communication skills. Knowledge of Interqual a plus!
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