Manager, Care Management
Keystone Mercy Health Plan - Philadelphia, PA

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Mgr, Care Management:

Under the supervision of the Sr. Director, Care Coordination, the Manager is responsible for Intensive Case Management (ICM) unit operations on a day to day basis. The Manager provides direct oversight of all Supervisors in Care Coordination ICM unit. The Manager is responsible for ensuring adequate staffing of the ICM unit. The Manager is charged with oversight of all existing policies and procedures and the development and implementation of new and revised KMHP Policies and Procedures impacting Care Coordination. . The Manager works collaboratively with all KMHP departments and providers to facilitate quality cost-effective care. The Manager is responsible to ensure consistency and conformance to all applicable standards and regulations including URAC, IBX, NCQA and all other applicable regulatory requirements. In addition to the responsibilities noted above, the Manager, Care Coordination (ICM) unit will act on the behalf of KMHP and the Sr. Director, of Care Coordination in various settings both on-site and off-site.

Principal Accountabilities:

  • Ensures effective daily operation of the Care Coordination department utilizing all applicable statutory provisions, contracts, and established policies and administrative procedures. Monitors case load assignments and makes appropriate adjustments based on staff experience, severity of cases and type of intervention(s) required. Provides coaching and counseling to improve productivity within the scope of HR policies and procedures.

  • Maintains a current knowledge of KMHP Policy and Procedure, DPW requirements, NCQA / URAC recommendations impacting Care Coordination assessment, access and delivery of services. Maintains understanding of Care Coordination role and impact on services including but not limited to, prior authorization, inpatient review, discharge planning, home health, and SNF/Rehabilitation services.

  • Maintains optimal staffing patterns based on current Care Coordination budget. Complies with all Human Resources Policies and Procedures for personnel requisitions, interviews and employment. Maintains accurate position control and organizational charts of assigned departments.

  • Develops and monitors goals and milestones designed to further the success of the ICM Unit within the Care Coordination Program. Adheres to the organization’s annual operating goals and strategic plan. Works collaboratively with Network Management, Informatics, Information Solutions, Quality Management, Utilization Management, and Public Affairs departments to integrate Care Coordination initiatives and goals with organizational programs

  • Participates with and advises Supervisors in the employee interview process. Participates in and coordinates the training and education of supervisory staff. Develops job descriptions for new positions if indicated.

  • Assists in the development, monitoring, evaluation and improvement of department systems in conjunction with the Sr. Director and Medical Directors and other KMHP/AMHP departments (i.e., Finance and I.S.) Participates as assigned in all quality management and improvement activities within the Care Coordination department.

  • Responsible for drafting quality improvement plans based on audit results, satisfaction results and other data opportunities for improvement in conjunction with the Sr. Director of Care Coordination.

  • Prepares reports and conducts analysis of operations/services as required by departmental, corporate, and/or regulatory requirements. Works collaboratively with Medical Informatics Department on identifying required data for reporting.

  • Establishes performance and productivity requirements and communicates expectations to management team. Works collaboratively with Supervisors in identification of individual and/ or group deficiencies in scheduled Performance Audits. Establishes action plan for assessment and resolution of identified issues.

  • Assists in preparation, coordination, and follow-up of IBC on site Case Management audits and DPW site visits pertaining to the Care Coordination Unit.

  • Completes performance evaluations of assigned staff. Coaches, counsels, and disciplines in accordance with HR policies and procedures. Participates in development, implementation, and monitoring of associate performance improvement plans.

  • Works collaboratively with Manager, Education and Training Department to identify educational needs of staff to maintain appropriate clinical expertise. Participates as indicated in the development and implementation of orientation and ongoing educational programs.

  • Oversees the collaborative efforts of the Supervisors to ensure that all new and existing staff are oriented to organizational and departmental policies and procedures. Ensures that credentials of all licensed staff are verified in accordance with licensing agency initially and prior to expiration date. Maintains current and accurate files of such licensure and ongoing education status. Ensures that staff meets minimal skill and clinical knowledge requirements to be successful in assigned role.

  • Participates in current process review and development of new and/or revised work processes, policies and procedures relating to Care Coordination responsibilities. Provides input into the development of educational material and programs necessary to meet KMHP business objectives, member/consumer (M/C) needs, and regulatory guidelines and staff professional development.

  • Partners with community agencies and contracted vendors to develop and maintain collaborative contact to assure M/Cs have access to the appropriate resources and to avoid duplication of efforts.

  • Monitors and oversees daily operations and strives to optimize the efficiency of coordination of care and service delivery for KMHP dual eligible members with a commercial health plan.

  • Acts as a liaison for KMHP with outsides entities, including, but not limited to physicians, hospitals, health care vendors, social service agencies, member advocates and regulatory agencies.

  • Participates in coordination of internal KMHP and external Provider directed communication regarding issues impacting M/C care coordination and delivery.

  • Creates and supports an environment which fosters teamwork, cooperation, respect, and diversity. Establishes and maintains positive communication and professional demeanor with KMHP employee and M/Cs at all times. Demonstrates and supports commitment to corporate goals and objectives.

  • Complies with Corporate, Federal, and State confidentiality standards to ensure the appropriate protection of M/C identifiable health information.

  • Maintains all necessary educational requirements for required licensure and certifications.

  • Performs other related duties and projects as assigned.

  • Adheres to KMHP policies and procedures.

  • Supports and carries out the Mercy Mission & Values.

  • Attends required training on an annual basis.

  • Position Qualifications/Requirements:

    Individuals who supervise case management practices, must have at least one of the following qualifications:

  • Education and Training:
  • A bachelors (or higher) degree in a health related field and licensure as a health professional (where such licensure is available); or
  • Certification as a case manager (as documented and accepted on URAC’s website@; or
  • Professional certification in a clinical speciality and at least three (3) years experience as a case manager; and
  • If they have directly supervised the case management process for three or more years, hold a certification as a case manager.

  • Licenses, Registrations or Certification
  • Valid driver’s license with car insurance

    Current unrestricted Pennsylvania Registered Nurse License required by the Commonwealth of Pennsylvania

  • Other
  • Certification as a Case Manager (as accepted by URAC) required within 1 year of accepting position.

    Three – five years of Case Management experience

    Three – five years of strong supervisory/management experience.

    Knowledge of Spanish, Russian, Vietnamese, or Cambodian as a second language is desirable.

    Keystone Mercy Health Plan - 2 years ago - save job
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    Keystone Mercy Health Plan thinks the key to good health is proper medical care. The firm provides health care benefits to more than...