Summary
Responsible for supervising the daily operations of the Care Management Department clinical programs and processes. Serves as the primary contact for staff, assigned to internal and external programs, and escalated care management issues. Including directly supporting clinical teams in clinical decision making, clinical evidence-based practice, and medical expertise. Assists Administrator/Manager with developing Care Management and utilization policies and procedures. Monitors internal and external policies and workflow for compliance regarding departmental goals. Provides support and supervision to internal clinical (licensed) and clinical support (non-licensed) department staff. Works under the direct supervision of the Care Management Administrator/Manager.
Duties
- Supervises the Utilization Management clinical (licensed) and clinical support (non-licensed) staff, as assigned.
- Serves as a resource for all team staff regarding program workflows, clinical documentation, claims processing system issues, and work distribution.
- Coordinates department workload and identifies staffing needs or other resources to meet quality, quantity, and departmental goals. Communicates changes in departmental processes and procedures to staff when necessary.
- Serves as primary contact for staff, assigned internal and external programs and escalated care management issues. Tracks and trends performance of assigned staff, using department metrics. Assists clinical and clinical support team with complex or escalated cases and notifies department Administrator or Manager as appropriate.
- Recommends promotion, termination, hiring or reassignment of subordinates including scheduling and conducting informal and formal employee performance reviews. Maintains attendance records and approves leave requests.
- Reviews performance issues with Administrator/Manager and makes recommendation regarding level of discipline. Develops communication form, action plan, and delivers disciplinary action after reviewing with the Administrator/Manager.
- Communicates outside the department to other Supervisors and leadership teams regarding specific member claim issues. Identifies potential process improvement opportunities across departments and makes recommendations to Administrators/Managers as appropriate.
- Audits staff processes and reviews cases with staff to assess compliance with established clinical and clinical support guidelines, workflows, and adherence to benefits structure and member progress towards goals. Consults with the Care Management Administrator/Manager regarding complex and/or high-profile cases.
- Produces routine and ad hoc reports to track staff productivity and program measures of success. Reviews reports, identifies issues, and trends, and makes recommendations to Administrator/Manager.
- Responsible for the development, implementation, and maintenance of Utilization Management policies and procedures. Collaborates with Administrator/Manager in creating, updating, and revising policies and workflows.
- Coordinates department project planning to accommodate the company's annual business needs. Works with management team to develop future programs and goals.
- Clinical resource for frontline clinicians on care plans, clinical evidence-based medicine, member health education, and medical expertise.
- Works directly with Medical Directors on member clinical interventions.
- Responsible for working with clinical staff and Medical Director regarding complex medical cases to assure services are clinically appropriate as well as ensuring services being reviewed and authorized are in accordance with National Guidelines.
- Assists with development of Utilization Management training materials. Identifies educational opportunities for the staff. Informs and collaborates with department educator to provide on-site educational opportunities.
Education Requirements
Requires a bachelor’s degree in clinical field for which the team has responsibility. (Example: Nursing teams would need a BSN)
Qualifications
- Associates degree in a related health field may be considered with 5 years of experience
- Eligibility to be licensed in all 50 United States
- Previous leadership experience preferred
- Relevant certifications preferred
- Demonstrates excellent verbal and written communications skills.
GEHA is an Equal Opportunity Employer, which means we will not discriminate against any individual based on sex, race, color, national origin, disability, religion, age, military status, genetic information, veteran status, pregnancy, marital status, gender identity, and sexual orientation, as well as all other characteristics and qualities protected by federal, state, or local law. We celebrate diversity and are committed to creating an inclusive environment for all employees.
