The Health Plan of San Mateo (HPSM), a managed care health plan, seeks a Senior Health Services Clinical Manager who will be responsible for the management, staffing, and clinical oversight of the Health Services, Care Coordination, and Utilization Management staff. Care coordination and utilization management processes within the Health Services Department have been developed to meet the needs of CMS-approved Model of Care and MediCal Managed care contract. Primary duties: Provide oversight and clinical guidance to the utilization management, and care coordination staff: including nurses, social workers and support staff. Ensure care coordination and utilization management functions are consistent with requirements of all HPSM product lines including CMS-approved Model of Care, MediCal managed care contract.
Direct supervision of care coordination and utilization management teams/staff. Continuously monitor care coordination and utilization processes for effectiveness and compliance. Develop training materials for utilization and case management and associated support functions to meet need of HPSM lines of business and Health Care initiatives (including Duals Demonstration project, CCS pilot program, and others) Assure members receive high quality, medically necessary care. Participate in the selection, training, monitoring, disciplining, mentoring, and evaluation of staff.
Evaluate and modify care coordination and utilization processes in order to respond to state audits and corrective action plans. Work collaboratively with other departments including Member Services, Claims, Grievance and Appeals to address member and provider concerns related to Health Services functions. Professionally represent departments and/or HPSM in internal and external meetings. Requirements: Education and Experience equivalent to: A Bachelor’s degree in nursing, pharmacy, social work or other healthcare related field; a Master’s degree is preferred.
A minimum of five years management experience in a health care and/or managed care field. Prior management experience Knowledge of: Utilization review and care coordination. Implementing and managing Medicare and Medi-Cal program requirements strongly preferred. Excellent oral/written communication skills, problem solving, planning, and organizational skills.
Experience with Medicare-SNP programs preferred. Ability to: Design and continuously improve case management programs and/or work processes. Provide guidance to/manage a multidisciplinary group of staff. Develop and maintain effective interpersonal relationships with others, including providers, members, community partners, public agencies, and government programs.
Communicate effectively, orally and in writing. BENEFITS INFORMATION: Excellent benefits package offered including HPSM paid premiums for employee’s coverage in the medical HMO plan and majority of PPO medical cost. Employee pays a small portion of the dependent premiums for medical and dental benefits. Additional HPSM benefits include fully paid vision, life, AD&D, STD, and LTD insurance; 457 Plan in lieu of social security (7.5% of salary/HPSM paid); retirement plan (10% of salary for compensation/HPSM paid); holiday and vacation pay; tuition reimbursement plan; and more.
APPLICATION PROCESS: To apply, submit a resume and cover letter with salary expectations to: Health Plan of San Mateo, Human Resources Department, 701 Gateway Blvd., Suite 400, South San Francisco, CA 94080. Email: firstname.lastname@example.org Fax: (650) 616-8039 File by: Continuous until filled. EOE Category: Clinical Specialist, Managerial