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|Job Category :||Management|
|Company Name:||Magellan Health|
|Position Name:||Manager, Care Management, Medicaid and Medicare|
|Location :||United States|
|Job Description :||This position performs the operational oversight role responsible for the day-to-day Care Management (CM) team and activities of prior authorization, assessment, reassessment, care planning, coordination of care and research and engagement of community and health services in the Medicaid and Medicare member markets. Possess behavioral health clinical knowledge, understands care management and prior authorization best practices and continuous learning skills. Fluent in medical record review, and understand the relationship between Care Management and primary care, community benefits, and other support opportunities. Responsible for maintaining a highly efficient workforce, meeting CM goals and contractual KPIs, and enhancing the performance of all licensed and non-licensed members of the CM Team. Works in a matrix environment with the Member Market Leads for Medicare and Medicaid.
Oversees care management (CM) team including recruiting, hiring; maintaining staffing competencies, productivity, and team ratios; monitoring qualitative and quantitative measures across all CM team members; and executing corrective actions as necessary.
Tracks and improves care management planning and outcomes across all member stratifications, seeking opportunities to improve and enhance Magellan’s performance in the market.
Oversees all CM operations including the development, documentation, implementation and communication of patient-centered care plans as a function of an interdisciplinary care team.
Oversees medical necessity reviews and prior authorizations.
Oversees and supports education of providers, supporting staff, members and families regarding care management role and health strategies; review all services rendered for appropriateness and levels of CM planning.
Instills a “team” mentality across all staff to support collaboration across licensed and unlicensed members to best execute care management planning and execution.
Monitors, tracks, and identifies trends in CM productivity and KPIs in partnership with the enterprise Quality team and use to adjust processes, procedures, and policies to improve workforce management productivity and operations metrics, or workflows.
Monitors individual team member performances for opportunities to improve effectiveness of member communication techniques; maintain operational dashboard for Care Managers and Care Support performance and reach out to appropriate training and support resources as needed.
Ensures that established policies, procedures, and guidelines are followed at high level of quality.
Monitors task baskets as appropriately assigned by role (to Care Managers & Care Support) and identify potential opportunities for efficiencies and improvements; identify areas where administrative or research tasks can be moved from Care Manager workflows to unlicensed team member workflows.
Works with Medicaid and Medicare Member Market Leads to ensure communication and contractual obligations, and goals are aligned to CM operational, quality, and medical cost KPIs and communicate achievement of performance standards; support ensuring compliance with Commercial regulations and requirements.
Works with Medicaid and Medicare Member Market Leads to develop effective pathways and scripts, stay up to date on market trends and best practices, and understand any opportunities to enhance team research into community support opportunities.
Other Job Requirements
Minimum 5 years of experience in health care, behavioral health, psychiatric or substance abuse health care setting.
Experience leading mixed clinical and administrative teams.
Experience with person-centered care organizations that support individualized plan development.
Experience with Care Management workflows and clinical pathways and/or prior authorizations.
Proficiency with enabling care management technologies, for example TruCare.
Strong organization, time management, and written and communication skills.
Ability to manage and oversee activities of a care plan.
Knowledge of utilization management procedures, mental health and substance abuse community resources and providers.
Knowledge and experience in inpatient and/or outpatient setting.
Understanding of plan benefit structures, psychiatric/medical terminology, call center terminology and operations.
Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their position; and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures.
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