MANAGER, Case Management-Health Net Federal Services (Rancho Cordova, CA)
Health Net Federal Services, LLC - 1500 - Rancho Cordova, CA

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Health Net, Inc. is a publicly traded managed care organization that delivers managed health care services through health plans and government-sponsored managed care plans. Its mission is to help people be healthy, secure and comfortable. Health Net, through its subsidiaries, provides and administers health benefits to approximately 5.4 million individuals across the country through group, individual, Medicare (including the Medicare prescription drug benefit commonly referred to as "Part D"), Medicaid, U.S. Department of Defense, including TRICARE, and Veterans Affairs programs. Health Net's behavioral health services subsidiary, Managed Health Network, Inc., provides behavioral health, substance abuse and employee assistance programs to approximately 4.9 million individuals, including Health Net's own health plan members. Health Net's subsidiaries also offer managed health care products related to prescription drugs, and offer managed health care product coordination for multi-region employers and administrative services for medical groups and self-funded benefits programs.

For more information on Health Net, Inc., please visit the company's website at www.healthnet.com.

JOB SUMMARY:
The Manager, Case Management, effectively manages a case management team and provides leadership and management of the services and activities of the regional case management function. Actively promotes an organizational culture committed to high quality customer service to clients and their families, physicians, and other members of the health care delivery system. Works collaboratively with Contracting department , Provider Relations, and administrators for the development and maintenance of clinically appropriate, cost-effective Case Management processes. Develops policies and procedures to improve efficiency and ensure a focus on outcomes.

ESSENTIAL DUTIES & RESPONSIBILITIES:

Effectively manages the daily operations and activities of staff (RN Case Managers and non-clinical staff) providing leadership and guidance:
  • Performs management duties including, but not limited to: performance management and evaluation,, staff development, coaching, training, disciplinary action, hiring, terminations, and setting goals and objectives.
  • Identifies department goals and objectives, develops and communicates action plans through regular staff meetings and other communications, using team approach to problem solving, setting clear expectations.
  • Seeks additional training opportunities through outside sources.
  • Develops monitoring systems and measurements and exhibits a customer service philosophy.
  • Establishes monitoring linkages between Transitional Care and other internal entities and departments when necessary.
  • Participates in corporate and state regulatory activities. Performs audit activities as required, and participates in establishment of corrective action as necessary.

Directs the effective coordination of health care services to achieve program goals & objectives:
  • Ensures that Case Management services comply with URAC and ISO standards by implementing applicable policies and procedures.
  • Communicates Health Net Federal Services goals & objects to the Case Management team and plans activities and strategy.
  • Works closely with the Provider Relations department to identify contractual needs in specific areas.
  • Researches and identifies appropriate equipment that will meet the beneficiary's needs and pursue contracts with these providers.

Manages the operations of the Case Management team to ensure best value health care services are delivered in a manner that satisfies beneficiaries:
  • Facilitates complex clinical and financial decision making by presenting thoroughly analyzed cases requiring higher administrative approval or intervention.
  • Works with staff in Claims and Billing departments to resolve complex claims and follows to resolution.
  • Negotiates with providers in securing coverage for services medically necessary and financially sound.

Establishes integrated continuous quality improvement process to assure high quality care, customer satisfaction, and contribution to financial performance:
  • Incorporates new work processes and approaches to improve efficiency and quality services.
  • Provides guidance to Case Management in resolving problematic situations with beneficiaries and families, physicians and external entities. Investigates and responds to client and provider complaints regarding quality of care.
  • Meets and collaborates with the MTF liaison regarding specific cases and troubleshoots high profile cases.

Participates in hands on team member training when appropriate and keeps team professionally current:
  • Assists staff as needed on difficult cases and provides educational opportunities with new and difficult cases.
  • Keeps current on industry trends and new development.
  • Participates and seeks educational forums for self and staff.
  • Participates in and involves staff in professional organizations.
Qualifications
REQUIREMENTS:
Education:
Bachelor's Degree in Nursing, Health Care Services, or other health related field

Certification/License:
  • Active, valid & unrestricted state of CA Registered Nurse license required.
  • Must possess one of the following Certifications: Commission for Case Manager Certification (CCMC), Case Management Administrator, Certified (CMAC), or Case Management Certified (CMC) credential.

Experience:
  • Previous experience in an HMO insurance or medical setting is highly desirable
  • Experience in Case Management program development and implementation required
  • Five years clinical experience required
  • Minimum of three years supervisory experience required, preferably with HMO experience in a medical management capacity
  • Project management experience is highly desirable

Knowledge, Skills & Abilities:
  • Specific understanding of medical management tools is necessary
  • Comprehensive knowledge of laws, regulations, and professional standards affecting case management practices in a managed care setting.
  • Knowledge of available health care and community resources.
  • Ability to interact effectively with key internal and external constituents, using collaboration and negotiation.
  • Demonstrated progressive patient management expertise required
  • Must have a "can-do" attitude and a proven successful track record in assessment, planning, implementation, coordination, monitoring and evaluation of the management of member's care
  • Computer Proficient in MS Office required.
  • Must be goal oriented; able to participate in a team environment with other motivated associates to move toward a common goal
  • Must have the ability to work in an environment of continuous process improvement
  • Ability to travel is required

Working Conditions:
The following section describes the general physical requirements for this position. Please note that 'constant' refers to more than 81% of time; 'significant' refers to 40-80%; and 'moderate' refers to 20-40% of the time.
Operates personal computers, printers, facsimile, telephones, copy machines and other commonly used office accessories/equipment.
Exposed to confidential information and expected to maintain confidentiality at all times; must adhere to HIPAA rules and regulations.
May be required to work outside of normally scheduled hours as mandated by the client, project and/or workload (e.g. evenings, weekends, and/or holidays).
May be required to maintain established work pace, meet deadlines; may have last minute urgent requests.
Physical activity may include: twisting, reaching, kneeling, bending, stooping, squatting, crawling, grasping, grabbing, pushing, pulling, repetitive motion, climbing, etc.
Required to have visual acuity to determine the accuracy, neatness, and thoroughness of the work assigned.
Required to have hearing ability to receive detailed information through oral communication.
Required to have speaking ability to express or exchange ideas.
Constant computer usage including constant typing and/or eye strain.
Constant repetitive arm, wrist, hand and finger motions -- making repetitive movements (e.g. key boarding, filing, data entry).
Constant phone usage; headsets may be required.
Significant travel may be required between work sites and/or out of area.
Constant sedentary work (desk bound or seated).
Constant reading is required via computer screen and/or bound printed materials.
Constant concentration may be required on various subjects by listening, reading and thinking clearly.
Constant interaction with others may be required. May need to listen, think, and speak in order to interact with others. Business interactions and behavior between coworkers and/or external customers are required. This may require face-to-face or telephone interactions.
Constant thinking at work may include listening, learning, analyzing, evaluating, and the ability to interpret what is seen and/or heard, or to link information from one or several things to the next.

OR
Any combination of academic education, professional training or work experience, which demonstrates the ability to perform the duties of the position.