Responsible for supervising the Case Management team, facilitating utilization management and team quality improvement activities. Helps to develop and implement department programs, work plans, and policies and procedures related to daily workflow for the Team. Collaborates effectively with this team to assure smooth transitions across the continuum of care for health plan members.
Duties and Responsibilities:
Job Duty : Direct Supervisor
Functions as a direct supervisor of staff for Case Management Responsible for daily supervisory functions, including supervising staffing, ensuring employee productivity, and work quality. Acts as both a clinical and administrative resource to staff in assessing member needs, devising/implementing plans of care, and facilitating the case management process
Job Duty: Oversight of Programs
Responsible for oversight of the Case Management Program. Acts as both a clinical and administrative resource to staff in administering care to members in these programs
Coordinates with other healthcare professionals to assure the best possible outcome in the most cost effective manner
Job Duty: Staffing
Screens and interviews potential applicants
Responsible for coordination of the Case Management staff schedules to ensure adequate work coverage during business hours
Reviews and approves “Requests for Paid Time Off” and manages employee timekeeping on an ongoing basis
Job Duty: Training
Collaborates with the UM Trainer for new staff training on the Core Competencies involved in their job
Responsible for coordinating training to staff after the original new employee training to ensure development of staff in the identified areas of core competencies. This training empowers staff to meet both quality and productivity goals of the clinical case management unit
Responsible for ongoing staff training in collaboration with other leadership members
Job Duties: Monitors current work of the CM Unit
Monitors daily/ weekly /monthly work volumes of the Case Management unit. Adjusts work as needed
Responsible for oversight of the Patient Review
Job Duties: Monitors work assignments
Monitors current CM case assignments and adjusts as necessary
Assigns cases or work coverage as needed
Job Duty: Collaborates with the Quality Review Program Works in collaboration with the Quality Review Specialist to ensure quality clinical services.
Collaborates with the Quality Specialist to maintain current standards for the CLCM unit and all programs
Job Duties: Development of Policy and Procedures
Assists with the development of policies and procedures desk reference material, work flows and resource materials for the CM Department Staff
Job Duties: Liaison to internal and external customers
Liaison to both internal and external customers on behalf of both the health plan and the unit. Works to maintain and develop relationships with both internal and external customers
Works to coordinate follow up for members discharged from the hospital.
Job Duties: Meetings Attends\ plans meetings related to case management issues Case Management Monthly Team Meeting
Meets individually with staff at a minimum of quarterly, ideally monthly.
Job Duties Collaborates with the Manager and Leadership team
Collaborates with and keeps the Manager, Director and the Leadership team apprised of workflow issues, staffing needs, system issues and needs for process improvement.
Job Duties: Reporting
Ensures daily, weekly monthly data available as needed to monitor programs, staff quality and productivity.
Collaborates with the Data Specialist for development of reports and timely filing of needed data and reports.
Performs other special projects and duties as assigned
Meets attendance guidelines per Molina Healthcare policy
Knowledge, Skills and Abilities:
Knowledge of a variety of clinical areas of medical treatment.
Knowledge of hospital/patient care facilities, current practices, procedures, and acceptable medical treatment and diagnoses.
Skill to learn company policies and procedures as they relate to hospital authorization/denials, physician review, appeals, etc.
Skill in both oral and written communications to ensure the accurate transfer of information and to build rapport that will ensure the trust, confidence and cooperation of others in a work situation.
Skill in establishing and maintaining a variety of records necessary to provide complete information and documentation for relevant and appropriate medical determination.
Skill to establish and maintain effective work relationships with those contacted in the performance of required duties.
Knowledge of ICD-9, CPT coding & HCPC
Familiarity with NCQA standards, regulations and measurement techniques
Intermediate knowledge and use of multiple software programs (i.e., Word & Excel), including excellent typing skills.
Effective skills in written and verbal communication and problem solving
Ability to educate others using a variety of media
Works cooperatively with other departments to ensure excellent service to members, physicians, and internal customers in all aspects of the medical care delivery system and reimbursement.
Excellent verbal and written communication skills
Ability to abide by Molina’s policies
Maintain regular attendance based on agreed-upon schedule
Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA)
Ability to establish and maintain positive and effective work relationships with coworkers, clients, members, providers and customers
Registered Nursing Degree
Bachelor’s of Science Degree in Nursing or related field
1-2 years of medical/surgical nursing experience
1 year supervisory experience
2 years Utilization Management or Case Management experience
HMO or Managed Care experience
Valid CA State Register Nursing license (BSN preferred)
Capability of transporting self to various locations. If operating a motor vehicle, must have a valid CA Driver’s License. If using own vehicle, must have proof of insurance coverage that at least meets current state minimum requirements.
Case Management certification
To all current Molina employees if you are interested in applying for this position please fill out an Employee Transfer Request Form (ETR) and attach it to your profile when applying online. Be sure to let us know you are a current employee by selecting “Molina Employee (current) in the source section of the online application.
Molina Healthcare offers competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V
Molina Healthcare - 2 years ago
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