Responsible for oversight of defined Health Services programs, services, or functions which may include, but not be limited to, condition/disease management program, behavioral health services, complex case management, UM/CM, grievance and appeals, claim review, and/or policy/procedure writing. Will carry a caseload consistent with scope of responsibilities, and may be called upon to perform routine day-to-day program functions. Actively participates in program development and implementation. Supervises and provides guidance to direct reports and other department staff regarding company policies, procedures, and operations. Manages the quality and productivity of team tasks and workflow as they relate to both assigned functions and the overall effectiveness of the Health Services team. Works to resolve issues and improve processes and outcomes.
Fosters teamwork, manages change, encourages innovation, builds collaborative relationships, encourages involvement and initiative, and develops goal orientation in others. Participates in hiring, training, coaching, counseling, and performance evaluation process of direct reports.
Take a leadership role in the development, implementation, and ongoing operation & maintenance of assigned program, service, or function.
Improve the performance of the department through effective oversight and coaching of team members, managing team performance and improving processes and outcomes. Monitor daily workflow and caseloads and other work processes of team to assure appropriate distribution and processing of tasks.
Orient and train new hires.
Provide ongoing supervision, training, evaluation, and leadership to assigned team members. This may include annual reviews, involvement in promotions and/or terminations of employees.
Participate in hiring decisions in concert with Medical Services Director and/or Medical Services Manager and HR.
Monitor and evaluate team assignments relating to volumes, timelines, accuracy, customer service, and other quality and performance measures, and take actions as appropriate.
Work cooperatively with department management and staff to ensure that work processes are well-ordered and managed appropriately. Provide backup to other departmental teams or management staff, as needed.
Serve as liaison with other PacificSource departments or community partners to coordinate optimal provision of service and information. Serve on various internal and external committees as required or designated. Document and report any pertinent communications back to the team or department.
Utilize and promote use of evidence-based medicine criteria.
Maintain modified caseload consistent with assigned responsibilities.
Facilitate investigation and resolution of process-related issues as needed. Facilitate conflict resolution, including interfacing with affected departments and individuals, as appropriate.
Oversee and assist in providing exceptional service and information to members, providers, employers, agents, and other external and internal customers.
Relate new or revised policies, procedures and /or processes to team members to ensure they have the most up‐to‐date and current information.
Facilitate team operations by discussions through the sharing of information and knowledge, identification of teamwork issues, development of problem‐solving recommendations, and recommendations of standardizing Health Services operations.
Represent the Heath Services Department, both internally and externally, as requested by Health Services Manager and/or Director.
Perform other duties as assigned.
Work Experience: Five years clinical experience, including case management experience. Minimum of three years direct health plan experience in the following areas: case management, utilization management, behavioral health, and/or disease/condition management. Prior supervisory experience preferred. Knowledge of health insurance and state mandated benefits.
Language skills: Excellent communication and negotiation skills, both verbal and written.
Reasoning Ability : Makes decisions for care outside contractual benefits that are mutually beneficial and cost-effective for the member/patient and PacificSource.
Education, Certificates, Licenses, Registration: Registered Nurse or Licensed Clinical Social Worker with current appropriate state License. Certified Case Manager Certification, or equivalent, strongly desired or willingness to obtain certification within 2 years of hire.
Other Skills and Abilities: Thorough knowledge and understanding of medical procedures, diagnoses, care modalities, procedure codes, including ICD-9, CPT Codes, health insurance and State of Oregon mandated benefits. Effective adult education/teaching and/or group leadership skills. Ability to deal effectively with people who have various health issues and concerns. Strong analytical and organizational skills with experience in using information systems and computer applications. Is flexible. Ability to develop, review, and evaluate utilization and case management reports. Good computer skills including experience with Word, Excel, and PowerPoint. Ability to use audio-visual equipment. Ability to work independently with minimal supervision.
Work inside in a general office setting with ergonomically configured equipment and some outside service calls, including visits to other health care settings.
Mental / Physical Requirements:
Requires sitting, standing, walking, stooping and bending according to work tasks. Light lifting and carrying of files and department notebooks. Must be able to read text and numbers and communicate clearly and distinctly using a voice telephone and in person. Handles files, computer keyboard, and writing instruments. May be required to make site visits.
This job description indicates the general nature and level of work performed by employees within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of employees assigned to this job.
PacificSource is an equal opportunity and affirmative action employer.
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