Summary

This position is responsible for leadership and management of the Health Plan Care Coordination Department, inclusive of management of the Transitions of Care (TOC), Complex Care Management (CCM), Population Health Management/Disease Management (PHM/DM) and Dual Special Needs Program (D-SNP). The Manager will establish and lead strategy for communications, protocols and procedures for all care coordination activities and coordinate as needed with other DHHA and DHMP departments. The DHMP Operations Manager for Care Coordination will be the primary contact for provider and Member care coordination operational questions and concerns, both inside and external to the organization. The position will liaison with DHMP Health Plan Services and other departments to support issue resolution and improved processes for Care Coordination activities. Manager will also liaison with DHHA Ambulatory Care Services (ACS) and inpatient hospital Care Coordination to align care coordination services throughout the integrated system. The manager is responsible for implementation and monitoring of compliance requirements, and will help prepare for and assist with all regulatory and compliance reviews. The manager will perform analyses of quality and performance measures, and implement performance improvement strategies to address variances. The Manager is responsible for monitoring adherence to federal and state regulations, policies, and operations procedures related to care coordination, inclusive of the Centers for Medicare and Medicaid Services (CMS), the Colorado Department of Insurance (DOI), the Colorado Department of Health Care Policy and Financing (HCPF) and the National Committee on Quality Assurance (NCQA) Health Plan Accreditation program. The Manager coordinates with the DHMP Compliance Officer for compliance associated with care coordination. The Operations Manager for Health Plan Care Coordination reports to the Director of Health Plan Medical Management and will support department-wide efforts to improve the cost and quality of clinical services delivered to Members.

Essential Duties and Responsibilities

1. Appropriately delegate and oversee responsibilities related to Health Plan Care Coordination, strategies for staff assignments, quality assurance monitoring and required reporting.

2. Hire, train, motivate and coach supervisors and staff to support efficient and accurate Care Coordination workflows

3. Hire, train, motivate and coach supervisors to assess employee performance and provide feedback and mentoring opportunities.

4. Identify, track trends and resolve conflicts or complaints from internal and external providers and staff. Work closely with Departmental leadership across the organization to develop and execute systematic solutions to common concerns from providers and staff.

5. Monitoring Care Coordination activity for quality, customer service and timeliness, and work with the Director to ensure the department is properly provisioned and staffed.

6. Analyze qualitative and quantitative monitoring reports to develop more effective or efficient processes and strategies for improving the cost and quality of care and care coordination services delivered to Members.

7. Work with the Director to establish and achieve Care Coordination department objectives, including improving the cost, quality and experience of care for Members.

8. Generate Care Coordination outcomes reports and presenting information to upper-level managers or other parties.

9. Ensure staff members follow company policies and procedures.

10. Manage RN staff supervisors - this includes coaching supervisors to be respectful and collaborative in their supervisory approach, cross-training supervisors and ensuring that there is a succession plan for all staff levels within care coordination programs.

11. Other duties as assigned.

Education and Experience

1. Bachelor's degree required.

2. Master's degree in health-administration or business-related field preferred.

3. Five years' experience in personnel and operations management including administration, supervision, human resources management, leadership and business development, required.

4. Health insurance managed care experience in Case Management/Care Coordination with direct Member contact required.

5. Experience with direct patient care in an acute, ambulatory care or community based care setting preferred

6. Professional experience and knowledge of medical management/nursing practices preferred.

7. Leadership and management experience focused in serving underserved (safety-net) populations, elderly, chronically ill, disabled, low income or frail population, preferred.

8. Medicare Advantage or Dual Eligible and/or Medicaid experience, preferred.

9. Experienced in collaborative leadership and teambuilding skills including influencing, leading and directing individuals in multiple functional areas.

Knowledge, Skills and Abilities

1. Strong understanding of business management, financial, and leadership principles.

2. Excellent communication, interpersonal, leadership, coaching, and conflict resolution skills.

3. Time and project management skills.

4. Ability to analyze processes and information, identify problems and trends, and develop effective solutions and strategies.

5. Commitment to providing exceptional service to customers and support to staff members.

6. Comprehensive knowledge and understanding of utilization management principles, programs, and processes

7. Ability to collaboratively lead team members and/or staff to achieve pre-determined goals. Effectively collaborate with and respond to varied personalities in differing emotional conditions, and maintain professional composure at all times. Strong customer service orientation and aptitude required. Use nursing process to assess, identify problems, analyze and integrate data, decide on plan of action, apply appropriate intervention, and evaluate outcomes. Evidence of leadership, creativity, integrity and initiative required. Ability to integrate within team environment.

Computers and Technology

1. Experience with windows-based computer programs and ability to use computer for data analysis and data display required.

2. Prefer experience with Medical Management platforms used to document care coordination services.

Certificates, Licenses and Registration

1. Active Registered Nurse (RN) License in the State of Colorado or a participating compact state preferred.

Supervisory Responsibilities

This position will be responsible for, but not limited to, hiring, terminating, performance management, coaching, supervision, fostering teamwork, training and development of one or more employees.