Care Management Resume Samples

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A Ledner

Adrien

Ledner

570 Don Lane

Detroit

+1 (555) 991 6101

570 Don Lane

Detroit

Phone

p +1 (555) 991 6101

Experience Experience

Phoenix, AZ

Care Management Coordinator

Phoenix, AZ

Goldner-Schneider

Phoenix, AZ

Care Management Coordinator

Maintain tracking and monitoring of assigned referrals at all levels of review for instant retrieval
Builds team spirit and interdepartmental rapport, using effective problem solving and motivational strategy
Strong problem solving and critical thinking abilities
Participates in the process of educating providers on managed care
Proficiency utilizing Microsoft Word, Outlook, Excel, Access, SharePoint, and Adobe programs
Identifies quality of care issues including delays in care
Identifies admissions no longer meeting criteria and refers care to plan Medical Directors for evaluation

Los Angeles, CA

Divisional Director of Care Management

Los Angeles, CA

Zemlak LLC

Los Angeles, CA

Divisional Director of Care Management

Support and provide direction to the Resident Service Director
May perform other duties as assigned
Ensure performance evaluations and merit increases promote
Responsible for resident care management throughout community
Create monthly staffing schedule and oversee weekly/daily compliance and coverage
Manage ongoing Quality Enhancement compliance
Successfully complete the Atria medication management training

present

Houston, TX

Senior Medical Director of Care Management

Houston, TX

Keebler, Kunze and Durgan

present

Houston, TX

Senior Medical Director of Care Management

present

Plans, directs and oversees annual budget development and ongoing management for all areas of responsibility
Develops and manages financial forecasts for entity
Establishes performance standards, identification of goals and outcomes
Optimize efficient patient care- related communications between and among hospital- based practitioners as well as with pre/post hospital providers of care
The position will also coordinate with the Chief Financial Officer and the Finance team to analyze and determine ROIs where pertinent for various care management programs within the ACO or other value based care initiatives
Develops and implements systems designed to maximize personal, team, and organizational success
Recognize that staff development is an essential building block for organizational success

Education Education

Bachelor’s Degree in Nursing

University of Oregon

Bachelor’s Degree in Nursing

Skills Skills

Possess excellent communication and organizational skills with the ability to multi-task, set priorities, and meet deadlines
Ability to perform multiple tasks and possess strong organization skills
Proficient in Excel spreadsheets
Demonstrate exceptional telephone skills
Demonstrated proficiency in Microsoft Office, Email and general computer functions
Results and goal-oriented with a philosophy for quality improvement
Strong communications skills
Ability to communicate effectively with patients and all levels of personnel in a professional, courteous and effective manner using excellent customer service skills
Ability to follow written and oral instructions and to work with general guidance
Knowledge of HIPAA regulations

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15 Care Management resume templates

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Care Management Coordinator Resume Examples & Samples

1+ year of Customer Services experience
1+ years of experience working in a Managed Care setting, Medical Office or Facility setting with demonstration of Medical Administration duties
Associate's or Bachelor's Degree in related field

Supervisor of Care Management Resume Examples & Samples

RN / BSN
4+ of LTHHC or CHHA experience
Experience in a home care setting
Prior supervisory/managerial experience

Assistant Director Care Management Resume Examples & Samples

RN or MSW
5+ years of management experience
Experience in a managed care organization, PACE, MLTCP, CHHA, licensed agency or a Lombardi program

Care Management Coordinator Resume Examples & Samples

Previous Concurrent / Utilization Review experience
Excellent clinical knowledge of disease entities
Computer / tech savvy

Careplus Care Management Coordinator Resume Examples & Samples

Bilingual Required
Proficiency in all Microsoft Office applications, including Word, Excel and Outlook
Associate’s or Bachelor’s Degree in Business, Finance or a related field
Previous experience working in the healthcare industry a plus

Director of Care Management Resume Examples & Samples

5+ years of Clinical experience in acute care, home care, and/or long term care in nursing leadership
BA/BS/BSN in Nursing
Master's Degree or evidence of current enrollment in an accredited program
CT RN license
Management experience from within case management
Knowledge of continuity of care including health care systems, reimbursement systems and regulations that pertain to areas of responsibility
Acute Care experience

Care Management Supervisor Resume Examples & Samples

2+ years of Post-Master’s Supervisory experience
Master's Degree in Counseling, Criminal Justice, Psychology, and/or Social Work
Licensed Clinical Social Worker (LCSW), Licensed Master Social Worker (LMSW) or Licensed Counselor
Strong Case Management background
Proficient in performing strength and needs assessment
Ability to interact and communicate with individuals at all levels to achieve results

Care Management Team Leader Resume Examples & Samples

BA/BS in health or human services field or LPN with 2 years of experience in related field; or BA/BS with 5 years of experience in related field
Experience in working with one of the following communities: chronic disease including HIV/AIDS; Substance use; Mentally ill; and Lesbian, Gay and Transgender
Excellent written and verbal communication skills in English
Ability to work well within the organizational structure
Proficient in Word, Excel, PowerPoint
Advanced degree in health or human services field with 1 year of experience in a related field
Experience supervising paid staff
Fluency in French, Spanish or one of Asian language
Familiarity with AIRS and eCW
Prior Outreach / Field experience

Care Management Team Leader Resume Examples & Samples

2+ years of experience with a Bachelor's Degree in Health or Human Services field or Licensed Practical Nurse (LPN) certification; 5+ years of related work experience with a Bachelor's Degree in a related field
Experience in working with one of the following communities is required: chronic disease including HIV/AIDS; Substance user; Mentally ill; and Lesbian, Gay and Transgender (LGT)
Microsoft Office/Suite proficient (Word, Excel, Outlook, PowerPoint, etc.)
1+ year of experience with an Advanced Degree
Bilingual (English and Spanish, Cantonese / Mandarin, or Bengali)

Director, Care Management Resume Examples & Samples

Registered Nurse with active license in the state of Virginia or master level Social Worker with active license in the state of Virginia (LCSW, LMSW or LAPSW)
3 years of relevant health care experience, preferably in managed and/or long-term care
3 years of experience providing care coordination to persons receiving long-term care and/or home and community based services, Medicare, Medicaid, Duals and/or Special Needs Programs
3 - 5 years supervisory/management experience required
Demonstrated ability to communicate with members with complex medical needs that may have communication barrier
Experience navigating resources and computer systems to access information
Intermediate to advanced software application and hardware expertise
Promote teamwork and a positive working environment
Possess a strong attention to detail, sound advanced critical thinking and follow up skills
Intermediate to advanced healthcare financial acumen, preferred
Ability to manage multiple priorities simultaneously; and work within contractual timelines and short turn-around times
Ability to anticipate reporting needs and identify areas for improvement
Demonstrated ability to work effectively in vertically-matrix organizations

Cancer Care Management Resume Examples & Samples

Functions within a team environment for the purpose of facilitating a strong, consistent medical/nursing collaborative presence in the care of our patient in all phases of their illness
Implements diagnostic and therapeutic interventions within the established, multidisciplinary, collaborative physician plan of patient care
Initiates routine admission orders and modifies treatments and medications (if prescriptive authority privileges have been granted) within established guidelines
Carries out critical skill as outlined in procedures and specific standards
Initiates and interprets laboratory, x-rays and other diagnostic tests and results as necessary and appropriate
Provides supervision and direction to other team members
Maintain the STS national database by entering all the thoracic surgery patients and outcomes into the database
Provide counseling and instruction regarding common patient problems and in depth education regarding any planned inpatient procedures/testing, and post-discharge medical care
Graduate of an accredited APRN program
Licensed or license eligible in the state of DE
Experience in oncology as APRN preferred, but not required

Director, Care Management Resume Examples & Samples

Educates staff regarding effective allocation of the hospital’s resources while encouraging provision of high quality patient care
Ensures appropriate communication of patient admission status to patients, physicians and other hospital personnel as appropriate
Communicates with attending physicians regarding admission status criteria and clinical signs and symptoms needed to support treatment in the hospital setting
Ensures care coordination staff remain aware of the varying third-party payer requirements for hospital services and notification of such services
Interview and evaluate assigned staff performance including annual performance reviews, performance improvement plans and disciplinary steps pursuant to Hospital’s Human Resource policies and procedures
Ensures consistent processes are in place to perform an initial assessment of patients in the hospital setting within 24 hours of admission focused on immediate short term and transition of care needs to drive expected length of stay consistent with the working DRG
Is cognizant of regulations and policies of all review organizations relating to billing of the services provided in the hospital setting, monitors and evaluates options and services to meet patient’s health needs
In conjunctions with the compliance department, ensures regulatory patient notification requirements are met and document within the patient’s medical record
Ensures patients are notified of change in admission status consistent with regulatory requirements
Monitor need for HINN, HRR and Important Message from Medicare. Confer with Care Management staff and supervise issuance of HINN or HRR letters
Work in conjunction with compliance and legal staff for court filings associated with psychiatric holds, guardianship and any other legal proceedings necessary to coordinate the timely care of hospital patients
Development and implementation of daily workflows to meet requirements of Discharge Planning Conditions of Participation
Supervises a full range of case management services provided to patients in the hospital setting; including
Training staff in Care Management Department workflows and Hospital policies and procedures related to care management;Training and directing staff in the use of the discharge assessments, care management and discharge planning worklists and documentation of care management services within Cerner PowerChart
Ensures quality of documentation of utilization review efforts and actively participates in the managing hospital utilization across the Continuum of Care to full efficiency
Evaluate staffing levels and assignments to ensure maximum efficiency and coverage for Care Management Services 7 days per week
Tracks and monitors accuracy and timeliness of Cerner documentation by staff
Provides care coordination coverage in the event of staffing shortfalls
Works with the Director of Care Management to prepare reports for the Utilization Review Committee and other such committees as designated by Hospital
Works in conjunction with Clinical Documentation Improvement department to develop and continue a positive working environment between the Care Coordination and CDI departments
Collaborates with the Director of Care Management and the Manager Utilization Review to ensure the effective operation of the Care Management department
Develops and maintains relationships with post-acute-care services providers necessary to coordinate the appropriate utilization of hospital resources and meet the clinical needs of hospital patients;Maintains a positive working relationship with Chief Medical Officer and any external physician advisor(s)
Investigates and follows up on complaints, grievances and quality issues related to care coordination, discharge planning and post-discharge services arranged by care coordination staff
In conjunction with the Director of Care Management, develop and implement policies to reinforce high quality, efficient work flows for care coordination
Licensed as a Registered Nurse or LCSW in the State of Florida
Certification in clinical case management strongly desired
Bachelor’s degree in Nursing (BSN) or Associate’s degree in Nursing (ASN) with Bachelor’s degree in a closely related field required or Master’s Degree in Social Work (MSW)
Minimum of 5 years of care coordination or discharge planning experience, preferably in a hospital setting. A minimum of 3 years of supervisory or team leadership experience strongly preferred
Ability to effectively use MS Word, PowerPoint, Excel and Outlook required
Ability to accurately complete tasks within established times

Inpatient Care Management Medical Director Resume Examples & Samples

UnitedHealthcare’s care management approach is data driven, and grounded in the use and application of evidence based medicine (EBM) and guidelines. The successful UCS medical director appreciates and understands data, is a champion of and is very conversant with evidence-based medicine, and uses nationally recognized clinical guidelines to teach and direct clinical staff, as well as engage the practicing community in discussions designed to result in individual patients receiving the right care, in the right place, at the right time
Through daily support of the UCS nurses, the medical director serves as a primary clinical educator and mentor, and facilitates achievement of appropriate patient care goals through guiding nurses and conducting peer-to-peer communication with practicing physicians
In addition, through the sharing of data and the promotion of EBM dialogue, the UCS medical director may engage with hospitals and/or local physician groups in forums designed to accomplish systemic change
Is a champion of EBM, and in particular of MCG which currently are the company’s primary review guidelines
Engages daily and ongoing with line inpatient review nurses, reviewing cases electronically or in verbal case discussion, (and less often in group discussion) with the goals of achieving the delivery of the right care at the right time in the most appropriate setting. Seeks opportunities for clinically appropriate behavior change based upon EBM, and accomplishing same with the practicing community
As a clinical resource and coach, assists nurses in having and improving insight into where and when opportunity exists. Helps nurses develop the skills and willingness to engage physicians in EBM discussion
Develops and delivers clinical education programs that address the specific needs of the local team; instructs individual nurses to understand and apply review guidelines, as well as engage with the practicing community
Promotes referrals to case management programs as part of longitudinal care management with the objective of reducing admissions and readmissions
Through use and/or analysis of available data (e.g., APR/DRG), identifies more global opportunities for intervention that may 1) better focus available review resources and activities, and/or 2) change practice or hospital habit
Assists in developing clinical strategy, identifying areas of clinical focus, developing initiatives to improve appropriate inpatient utilization and other functions and representing same to senior management
Concisely and articulately documents case review findings, actions and outcomes in electronic systems, and meets medical director inter-rater reliability and quality guidelines
Regularly engages in peer-to-peer dialogue with practicing physicians about the care of individual inpatients to develop collaborative intervention plans based upon EBM
Engages with employees from other business units (e.g., market medical directors, contracting personnel) to discuss and develop strategies to promote systemic network change based upon identified operational efficiencies or gaps from EBM. As needed, may meet with physician groups and/or hospital personnel
With operational leadership, monitors site-specific operations dashboard data, identifying opportunities and assisting in the development of appropriate action plans
Participates in national forums, sharing ideas on best practices with other medical directors and clinical leaders from other UCS sites. As need and opportunity present, participates in national committees and/or the design/redesign and development of programs
Works in close collaboration with site nursing leadership to provide strong leadership to staff. Supports and champions operational change
As needed, participates in other utilization management activities such as pre-certification review, appeals and grievance adjudication, etc
Licensed physician; Board Certified in ABMS/ABOMS specialty
5+ years clinical practice experience
Supervisory skills, including clinical mentoring and coaching expertise
Excellent interpersonal communication skills (telephonic and face to face)
The ability to establish rapport with physicians in peer-to-peer communications in frequent daily calls to physicians and facilities regarding perceived gaps in EBM and problem solving to close those gaps
Knowledge of managed care industry
Data analysis and interpretation experience and skills
Strong belief in EBM philosophy
Creative problem solving skills; training in Six Sigma methodology preferred
Strong team player with team building skills
Comfortable with change, and able to lead others through it

Hospice Care-management Resume Examples & Samples

Displays decision making based on prior practices or policy, with some interpretation
Solves problems and / or reviews facts, and selects the best solution from identifying alternatives with the ability to apply individual reasoning to the solution of a problem and identifies and reports processes or procedures that require modification
Provides assistance with orientation and mentoring of new case managers
Reviews difficult and / or exceptional preauthorization requests
Ensures the identification or potential early-discharge to reduce LOS or prevent hospital admissions
Regular attendance at PCC in assigned region, mentoring lower level case managers; reviews referrals prior to PCC, assists with complicated referral requests and assists with concerns and benefit application
Manages difficult, complex and catastrophic patients
Offers resourceful planning of alternative services when a specific setting or service is not available in the admission facility when approached by assigned team members
Attends and contributes to strategic planning meetings at assigned team clinics as well as to departmental processing improvement meetings
Oversees telephonic case management staff and UM out patient care coordination staff and ensures compliance with approved standardized guidelines, regulations and contractual agreements
Monitors employees for excessive work and inability to complete position responsibilities within a normal workday and provide time management advice to employees that are unable to complete position responsibilities
Takes ownership of the total work process and provides constructive information to minimize problems, increase customer satisfaction and improve job efficiency. Makes suggestions to appropriate managers as well as participates in the budgeting process by informing the manager of capital and operating needs
Maintains and stores supplies and equipment in a safe manner to eliminate / reduce safety risks
Strives to personally expand working knowledge of all aspects of WellMed departments
Attends educational offerings to keep abreast of changes and comply with licensing requirements
Conducts annual evaluations of team members in a timely basis; provides feedback in a constructive manner and respects the confidentiality of personnel issues
Participates in UM / quality improvement committees and conducts special UM / QI studies as necessary
Liaison to market providers for UM providers
Fosters discharge plan collaboration with patient / family, attending physician and facility Case Manager
Performs all duties to customers in a prompt, pleasant, professional and responsible manner regardless of the stressful nature of the situation and always identifies self by name and title
Guides and answers benefit questions, contract issues, and updates physicians / medical groups of preferred contracts, providers, facilities and hospital utilization and noncompliance issues
Completes Case Management Documentation System (CMDS) audits on a monthly basis to maintain CMDS entry, compliance with bed, day, and financial responsibility information on in-patient admission
Educates medical services personnel regarding utilization management policies, procedures and techniques
Oversees case managers and ensures compliance with approved standardized guidelines, regulatory requirements and contractual agreements while respecting the confidentiality of these agreements
Demonstrates thorough knowledge of health plan benefits and quality of care criteria of health plan as well keeping abreast and compliance with established and all new or revised WellMed policies and procedures when posted or distributed with accurate interpretation to customers
Mentors new employees and provides orientation as well as assists in the growth and development of associates by sharing special knowledge with others and trains and shares information with less experienced case managers to improve performance and outcomes of patient services
Supports the continuing education of assigned team with documentation compliance into the CMDS
Analyzes and reports aberrant utilization trends and plans intervention
Supervises daily UM processes and assigns tasks and projects according to workflow volume and requirements of the UM program
Assists with interviews, new employee selection and training for open positions and collaborates with all managers in placing candidates in the appropriate positions
Assesses and evaluates staff performance annually and assists in developing their skills with the goal of reaching highest aptitude for position and career goals
Coaches and counsels staff with performance concerns that require process improvement plans including monitoring and coaching for improved outcomes in collaboration with manager
Professional Nursing Degree with current RN License (in state of employment)
BSN or Associate’s Degree in Nursing
Five or more years experience in medical or ICU hospital based nursing or case management, discharge planning, utilization review or other cost containment role
Minimum of one year supervisory, team leader, or charge nurse experience required or one year successful case management experience
Experience related to advanced care planning and discussions with patients regarding end-of-life wishes
Two or more years of palliative and hospice experience
Must possess strong critical thinking, written and verbal interpersonal communication skills with ability to interact with professional and non-professional staff regarding healthcare issues
Working knowledge of the managed care referral process, case management, claims, contracting, and physician practice
25% travel
Medicare criteria knowledge
Sound knowledge of NCQA and federal regulations
Interqual or Milliman guidelines
Managed 15 plus staff

Manager of Clinical Care Management Resume Examples & Samples

Day to day oversight and management of a cross functional clinical team
Clinical operations across the continuum of care (assessing, planning, implementing, coordinating, monitoring and evaluating)
Responsible for daily, monthly and quarterly reports related to the Care Management team
Current, unrestricted CSW, LMHP, or LIMHP, in the State of Nebraska
3+ years of experience as a manager
3+ years of experience in one of the following areas or a combination of areas: Residential Treatment facility, group home, psychiatric hospital setting, IDD population case management, Behavioral Health discharge planning, BH Care management or service coordination
Experience developing programs and protocols

Associate Director Care Management Resume Examples & Samples

Implementation and oversight of all clinical management functions for individuals receiving care management (level one and two) program, including but not limited to: assessment, care coordination, interaction with state agencies and community organizations as related to care plan coordination, participant and caregiver education, and oversight of multi-disciplinary care conferences
Implementation and oversight of all program management functions, including but not limited to: compliance with program requirements, rules and regulations, implementation of and management of program policies, procedures and protocols that are aligned with federal and state requirements, with an emphasis on audit readiness
Participation in all audit reviews both internally and with external partners
Superior Excel and PowerPoint skills
Experience working with diverse groups of members, state/federal regulators, and stakeholders
Extensive knowledge of the continuum of care
Nebraska Registered Licensed Nurse
Must be a Nebraska resident
8+ years of clinical experience in health care clinical settings
5 years of extensive experience in leadership and management
Experience managing professional remote personnel
At least 5 years of experience in case management, LTSS, TCM IDD or Behavior Health populations
Certified in case management
Previously worked in a managed care sector

Care Management Coordinator Ahnj Resume Examples & Samples

Evaluate proposed plans of treatment, as defined in the precertification requirements of the group plan Using the medical criteria of InterQual and/or Medical Policy, establish the need for inpatient, continued stay and length of stay, procedures and ancillary services Directs the delivery of care to the most appropriate setting, while maintaining quality
Performs early identification of members to evaluate discharge planning needs
Collaborates with facility case management staff, physician and family to determine alternative setting at times and provide support to facilitate discharge to the most appropriate setting
Identifies and refers cases for case management and disease management
Identifies quality of care issues including delays in care
Appropriately refers cases to the Quality Management Department and/or Sr. Clinical Svcs Nurse when indicated
Utilization decisions are compliant with state, federal and accreditation regulations
Ensures that all key functions are documented via Care Management and Coordination Policy
Works to build relations with all providers and provides exceptional customer service
Reports potential utilization issues or trends to designated manager or senior clinical nurse and recommendations for improvement
Medical management/precertification experience preferred
Active NJ or PA Licensed Registered Nurse required

Divisional Director of Care Management Resume Examples & Samples

Monitor resident status to ensure that regulatory requirements and company established Resident Service Guidelines are met
Support and provide direction to the Resident Service Director
Ensure that community meets Quality Enhancement Standards
Review systems in the Care Department at the community level, and recommend best practices to implement system or maintain system
Teach and train assigned Resident Services Directors, and Care Staff
Roll out and recommend best practice for new policy or systems
Review regulations pertaining to area and help community to remain in state compliance
Maintain relationships and act as a resource to assigned Executive Directors, Resident Services Directors and Care staff
Setting up personal schedule, prioritizing need at community or Regional Vice President/Senior Vice Presidents direction or Care Department directive
Review actual Care Department expenses against budget. Make recommendations for communities to remain within budget. If related to staffing, assist with schedule and staffing recommendations
Ensure communities have adequate staff to meet the needs of residents
Responsible for resident care management throughout community
Ensure initial and ongoing assessments are timely and accurate
Ensure service plans and assignment sheets are accurate and current
Review communication book and follow-up on critical issues
Administer first-aide to residents as needed
Oversee the medication program throughout the community
Follow up on incident reports and document incidents (abuse, neglect) as needed consistent with Atria and state designated regulations and policies
Audit resident files for accuracy and to ensure compliance with regulations and policies
Conduct medical records (MARS) and med cart audits to ensure all aspects of medication program are being completed in compliance with regulations and policies
Correct any outstanding deficiencies related to resident services and follow up as needed with State survey point of contact
Oversee state regulatory compliance
Manage ongoing Quality Enhancement compliance
Receives and addresses resident/family concerns in an effective and compassionate manner
Ensures pro-active communication occurs with families as to residents status
Lead family meetings to review service plan updates/level of care changes
Assist with arranging for transportation with residents to their appointments as needed
Conduct training of staff by conducting timely in-services for frontline staff
Create monthly staffing schedule and oversee weekly/daily compliance and coverage
Review assignment sheets for Resident Services Assistants to ensure all duties have been performed and provide medication oversight for Resident Medication Assistants
Hire staff as needed and conduct orientation
Review communication log daily and coordinates resident care with appropriate staff
Ensure performance evaluations and merit increases promote
Participate in stand-up meetings to represent the Resident Services Department
Coordinate with other departments to ensure resident care is at the highest level
Maintains spend down log for purchases/others logs for Agency as utilized
Organize the Assisted Living office/dept and delegate essential functions as needed
Leverages relationships with hospitals, clinics, etc. to support sales
LPN/LVN required; RN preferred
Three or more years experience in a similar role in Assisted Living or Healthcare
Three or more years of experience providing program oversight in an organization consisting of multi-site operations
Appropriate state licensing where required
Able to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent
Active Driver’s License
Able to apply common sense understanding to carry out detailed but uninvolved written or oral instructions. Ability to deal with problems involving a few concrete variables in standardized situations
First Aid and CPR Certification if required by state law
Successfully complete the Atria medication management training
Available to work flexible work hours due to demands of position
Substantial travel will be required on behalf of Company
Position requires driving responsibilities (may use Company provided vehicle and/or personal vehicle)
Must possess valid driver’s license
Must satisfactorily meet and be in compliance with Atria motor vehicle policy standards

MGR Comprehensive Care Management Resume Examples & Samples

COORDINATES AND SUPPORTS ONGOING PROBLEM SOLVING RELATED TO CARE COORDINATION, DISCHARGE PLANNING, CASE MANAGEMENT AND UTILIZATION REVIEW
MONITORS PROCESSES AND SYSTEMS TO ENSURE EFFICIENT DELIVERY OF SERVICES. ESTABLISHES TOOLS, PROCESSES, AND SYSTEMS TO OPTIMIZE THE CASE MANAGEMENT ROLE
ENSURES APPROPRIATE PATIENT CARE NEEDS ARE MET AND TREATMENT PLANS ARE EXECUTED IN THE APPROPRIATE LEVEL OF THE CONTINUUM
DEVELOPS STRUCTURES, RELATIONSHIPS, AND PROCESSES TO FACILITATE PARTICIPATION BY PHYSICIANS, PHARMACISTS, NURSES, SOCIAL WORKERS AND OTHER HEALTH PROFESSIONALS IN MULTIDISCIPLINARY CARE PLANNING, CARE DELIVERY, AND DISCHARGE PLANNING
DEVELOPS AND IMPLEMENTS STANDARDIZED POLICES TO ACHIEVE EFFICIENCY OF OPERATIONS AND THE PROVISION OF OPTIMUM PATIENT CARE. ENSURES COMPLIANCE WITH ALL INSTITUTIONAL POLICIES AND REGULATORY REQUIREMENTS
ENSURES APPROPRIATE SCOPE OF PRACTICE BY STAFF. ENSURES THAT SUBORDINATES ARE FAMILIAR WITH PROMINENT ETHICAL STANDARDS IN THE PROFESSION, ESPECIALLY RELATED TO ISSUES SUCH AS CONFIDENTIALITY, INFORMED CONSENT, CONFLICTS OF INTEREST, DUAL RELATIONSHIPS, BOUNDARY ISSUES, DOCUMENTATION, CONSULTATION, REFERRAL, AND TERMINATION OF SERVICES
DEVELOPS MEANINGFUL PERFORMANCE MEASURES TO DETERMINE THE QUALITY, EFFECTIVENESS AND EFFICIENCY OF OPERATIONS IN ACHIEVING DESIRED OUTCOMES
KNOWLEDGE OF CARE COORDINATION, DISCHARGE PLANNING, CASE MANAGEMENT AND UTILIZATION REVIEW
KNOWLEDGE OF HUMAN BEHAVIOR AND PERFORMANCE; INDIVIDUAL DIFFERENCES IN ABILITY, PERSONALITY, AND INTERESTS; PSYCHOSOCIAL METHODS; AND THE
ASSESSMENT AND TREATMENT OF BEHAVIORAL AND AFFECTIVE DISORDERS
KNOWLEDGE OF THE PRINCIPLES AND METHODS TO RESTORE OR ENHANCE SOCIAL, PSYCHOSOCIAL, OR BIO-PSYCHOSOCIAL FUNCTIONING OF INDIVIDUALS, COUPLES, FAMILIES, GROUPS, ORGANIZATIONS AND COMMUNITIES
INTERPERSONAL SKILLS TO INTERACT WITH A WIDE RANGE OF CONSTITUENCIES
VERBAL AND WRITTEN COMMUNICATION SKILLS
SKILL IN THE USE OF PERSONAL COMPUTERS AND RELATED SOFTWARE APPLICATIONS
ABILITY TO DEVELOP STRUCTURES, RELATIONSHIPS, AND PROCESSES TO FACILITATE
MULTIDISCIPLINARY CARE PLANNING, CARE DELIVERY, AND DISCHARGE PLANNING
ABILITY TO STANDARDIZE POLICES, PROCEDURES, AND PROGRAMS
ABILITY TO ASSIST INDIVIDUALS IN RECOGNIZING AND SOLVING PROBLEMS
ABILITY TO SUPERVISE, TRAIN, MOTIVATE, PROVIDE GUIDANCE TO STAFF AND ENSURE THE CLINICAL COMPETENCY OF STAFF

Manager of Comprehensive Care Management Resume Examples & Samples

Knowledge of Care Coordination, Discharge Planning, Case Management and Utilization Review within an ACO Environment
Knowledge of human behavior and performance; individual differences in ability, personality and interests; psychological methods; and then assessment and treatment of behavioral and affective disorders
Knowledge of the principles and methods to restore or enhance social, psychosocial or bio-psychosocial functioning of individuals, couples, families, groups, organizations and communities. Interpersonal skills to interact with a wide range of constituencies, verbal and written communication skills
Computer and related software applications skills
Multidisciplinary care planning, care delivery and discharge planning
Ability to standardize policies, procedures and programs
Ability to assist individuals in recognizing and solving problems
Ability to supervise, train, motivate, provide guidance to staff and ensure the clinical competency of staff
Provide administrative, technical and clinical management of assigned staff in accordance with industry best practices which includes the responsibility for hiring, performance evaluation, performance improvement, education, staff development, work allocation and problem resolution
Coordinates and supports ongoing problem solving related to care coordination, discharge planning, case management and utilization review. Evaluates and monitors processes within other health systems to enhance and ensure the efficient delivery of quality services. Establish tools, processes and systems to optimize care coordination
Ensure appropriate patient care needs are met and treatment plans are executed in the appropriate level of the continuum
Develop structures, relationships and processes to facilitate participation by physicians, pharmacists, nurses, social workers and other healthcare professionals in multidisciplinary care planning, care delivery and discharge planning
Develop and Implement standardizes policies to achieve efficient operations and the provision of optimum patient care. Ensure compliance with all institutional policies and regulatory requirements
Ensure appropriate scope of practice by staff. Ensure that all subordinates are familiar with prominent ethical standards in the profession, especially related to issues such as confidentiality, informed consent, conflicts of interest, dual relationships, boundary issues, documentation, consultation, referral and termination of services
Develops meaningful performance measures to determine the quality, effectiveness and efficiency of operations in achieving desired outcomes

Supervisor Care Management RN Rancho Cordova Resume Examples & Samples

Directs personnel supervision of associates to include hiring, training and performance evaluations
Assures appropriate triage of members at risk
Supervises the assessment of members situations and functioning, assuring identification of individual needs
Assures assessment information is used to develop a comprehensive care management plan to address the members needs
Manages the planning process to assure the specific objectives, goals and actions are designed to meet the members needs as identified throughout the planning process
Responsible for implementing and coordinating activities that will lead to the accomplishment of goals set forth in the care management plan
Performs resource management, and organizes, secures, integrates and modifies resources to meet the goals
Assures processes are in place to identify deficits between benefits and member requirements, and utilizes community and ancillary services to assure continuity of care for the member
Performs the direct supervision of care managers, assures the proactive identification of members at risk and in need of care management services, and identifies educational opportunities
Assesses caseloads and realigns assignments to meet organizational needs
Works in collaboration with Medical Informatics and the Quality Improvement departments and monitors programs to meet the needs of our membership and those in the Care Management process
Monitors information from all relevant sources about the care management plan and activities to determine the plan's effectiveness
Performs the daily activities necessary to evaluate the effectiveness of the care management plan at appropriate intervals, and determines if outcomes were successful and goals were met
Works in collaboration with the Care Management Directors in each state to identify areas of opportunity and/or provider education
Maintains Care Management vendor relationships on a daily and aggregate basis to assure the care given to our members is appropriate and compliant with PHS policies and governmental regulatory requirements
Communicates with providers, members and community resources as necessary to support the planning, implementation and evaluation of the patient's plan of care
Performs audit activities as required, and participates in establishment of corrective action as necessary
Assures the use of appropriate criteria when making decisions
Performs Care Management activities as required
Current, valid and unrestricted professional RN licensure is required
Five years of clinical experience and at least two years of supervisory experience, preferably with HMO experience in a medical management capacity
Needs specific understanding of medical management tools
Demonstrated progressive patient management expertise required
Must have a can-do attitude and a proven successful track record in the assessing, planning, implementing, coordinating, monitoring and evaluating the management of member's care
Proficiency with Windows-based applications required
Must be goal oriented; able to participate in a team environment with other motivated associates to move toward common goals
Must have ability to work in an environment of continuous process improvement

Division Director of Care Management Resume Examples & Samples

Oversees the daily operation of the System Case Management and Social Services programs, ensuring accountability, effectiveness, efficiency, and compliance with regulatory and accreditation agencies
Serves as Clinical Advisor to Case Management across the continuum of care for all payment programs, including but not limited to participation in program development and facility network development
Participates in payor relations activities and physician networking development initiatives
Implements policies, institutes processes, and works with Facility leadership and Nursing to effectively manage length of stay
Develops and tracks accountability metrics to ensure quality and productivity of Facility Case Management departments
Acts as liaison for Information Services, Patient Financial Services, and other Corporate-level functions to ensure Case Management processes and procedures work efficiently across the Revenue Cycle
Develops strategic action plans and timelines for key areas of focus including RAC preparation, ongoing physician education, physician trends, denials, discharge planning, standard order sets, ICU level of care utilization, and other areas
Evaluates and ensures each facility’s level of compliance with Medicare Conditions of Participation, ensuring an effective and compliant UM committee
Oversees and monitors each facility’s UM plan, ensuring compliance with CMS regulations
Implements and provides oversight of CDQI operations to ensure activities are aligned with the overall strategic direction
Leads the short and long-term planning process, and drives prioritization to meet the Enterprise’s financial performance goals
Develops and implements best practices and consistent process/tools across care delivery businesses
Ensures application of clinical algorithms within attestation process to enhance ability of providers to assess and document the complete health status of members
In-depth knowledge of CMS regulations in both the inpatient and outpatient arenas is required
Broad-based knowledge regarding clinical practice, insurance and legal disciplines, hospital operations, and revenue cycle
Expert in problem resolution techniques
Excellent analytical skills, including data aggregation, analysis, interpretation, and application are required

Director Inpatient Care Management Resume Examples & Samples

Prioritizes activities for multiple markets; sets direction for manager(s) market(s)
Adapts department plans and priorities to address business challenges to include PTO management and caseload balancing
Provides daily input to forecasting and planning activities relevant staffing and facility coverage due to identified utilization trends and membership fluctuations. *Inpatient facilities include: Acute Care hospitals, Acute Inpatient Rehab, SNFs
Manages 4 direct reports (Managers- with 105 indirect reports, ICMs) including ongoing performance monitoring and completing annual MAP evaluations
Actively participates in individual market bed day action planning meetings (1X mo minimum) and communicates direction to managers and staff
Properly escalates concerns or operational issues impacting Region or Market(s)
Engages with internal Sr. Medical Director or Medical Directors regarding activities that impact both nursing and physicians, limited with external leadership
Supports and actively engages in projects for region/assigned markets and Enterprise-wide initiatives
Support and champion business standardization and flawless execution for business initiative
Support continuous improvement of annual employee engagement scores and champion of vital signs action team
BS or BSN degree required; advanced degree preferred
Minimum of 5 years hands on clinical experience including managed care
3+ years in a management role with focus on Utilization Management
Experience with the utilization of criteria based decision making tools, such as MCG, Interqual or other criteria-based guidelines
Microsoft Word, Outlook, Excel, PowerPoint
Strong demonstrated ability to build and maintain relationships
Effective communication and presentation skills, flexibility, displays positive attitude

Sales Director, Care Management Resume Examples & Samples

The Sales Lead is responsible for meeting or exceeding budgeted membership goals
Works under the direction of the VP of Field Operations to drive and achieve sales goals by leading or advancing the sales cycle
Develops and executes on strategic business plans to meet top line numbers
Serves as a subject matter expert on Optum Care Plus plans and all UnitedHealthcare Medicare products and maintains all current product certifications and appropriate licensure
Establishes priorities with and ensures successful completion of goals for all direct reports
Drives the Customer Relationship Management process at the site to include: ensure meetings held on a consistent basis, red/yellow accounts have action plans in place to address growth opportunities, clear accountability process to monitor issue resolution and outcomes, effectively manages new and same store accounts through execution of CRM
Works in conjunction with other members of the senior team to ensure a pipeline of viable nursing homes exists to meet targeted new development goals
Ensures self and sales agents conduct presentations, sales activities and other informational events in accordance with current approved communication and marketing programs and state / federal regulations
Participates in planning and implementation of outreach strategies and programs in conjunction with Clinical and Provider Relations staff
Ensures self and sales staff is compliant with all sales database and lead management requirements and reporting, detailed management of appropriate reporting/database systems, funnel management, customer information, territory planning, etc
Uses internal performance evaluation system to: establish, discuss and monitor direct report’s performance, create development plans and implement Corrective Action Plans as needed and as described in the performance management guidelines
Maintains a working knowledge of plan benefit, program changes, industry insights and regulatory requirements
Ensures compliance and quality of sales process components, adhering to all applicable state and federal regulatory requirements and Optum Policies and Procedures
Responsible for hiring, training and development of all sales staff
Performs other job related instructions as requested, with reasonable accommodation
Responsible for establishing and maintaining relationships with leadership in selected nursing homes
3+ years’ experience in Sales and Marketing
1+ years sales management experience
1+ years of successful business development experience in a service industry
Experience with lead management software (bConnected)
Sales Management Skills
Exemplary oral and written communication skills
Solid self-management and time management skills
Able to work effectively independently and within a team environment
Decision making / problem solving skills
Territory planning and management skills
Technical knowledge of the healthcare industry, especially long term care, Medicaid and Medicare
Ability to lift up to 50lbs on occasion
Must have or be able to obtain appropriate state insurance licensure, as soon as possible, not to exceed 60 days
Maintain licensure and product certification based on policies and procedures
Ability to work a variety of hours, early morning, evenings and weekends, as required by various sales activities
Will require local area field based travel and reliable transportation is necessary
Minimum of a Bachelor's degree or equivalent work experience
Experience in Medicare, Medicaid, Managed Care or Long Term Care industry
2+ years of proven direct healthcare related sales experience
Knowledge of and familiarity with Washington State Skilled Nursing Facilities, specifically in King, Pierce, Snohomish, Kitsap, Whatcom, and Spokane counties
Familiarity with LEAN electronic enrollment system
Active participation in local Aging Services Industry Association

Director Inpatient Care Management Resume Examples & Samples

Manages 4 direct reports (Managers- with approximately 100 indirect reports, ICMs) including ongoing performance monitoring and completing annual MAP evaluations
5+ years hands on clinical experience including managed care
High level proficiency from experience with the utilization of criteria based decision making tools, such as MCG, Interqual or other criteria-based guidelines
Proficient in Microsoft Word, Outlook, Excel, PowerPoint

Care Management Coordinator Resume Examples & Samples

Contacts attending physicians regarding treatment plans/plan of care and clarifies medical need for inpatient stay or continued inpatient care
Identifies admissions no longer meeting criteria and refers care to plan Medical Directors for evaluation
Presents cases to Medical Directors that do not meet established criteria and provides pertinent information regarding member’s medical condition and the potential home care needs
Maintains the integrity of the system information by timely, accurate data entry
Participates in the process of educating providers on managed care
Open to new ideas and methods; creates and acts on new opportunities; is flexible and adaptable
***This position has the ability to be work from home following training****
Minimum five years clinical experience or equivalent (Intensive Care, Trauma, Home Health a plus) required
Oriented in current trends of medical practice

Care Management Team Leader Resume Examples & Samples

Bachelor's Degree in health or human services field; or LPN with 2 years of experience in related field; or Bachelor's Degree with 5 years of experience in related field
Experience working with one of the following communities: chronic disease including HIV/AIDS; Substance abuse; Mentally ill; LGBT
Excellent people skills with professional demeanor
Ability to use common office software. (Word, Excel, Power Point)
Fluency in French, Spanish or one of Asian languages
Advanced degree in above mentioned field with one (1) year of experience in related field

Assistant Director, Care Management Resume Examples & Samples

Minimum of five years in managed care administration with three to five years experience in Case Management in a capitated insurance setting
Three years hands-on experience with automated authorization systems and information analysis
Experience in leading innovative case management programs
Experience in business development and team-building programs
Proven ability to supervise, develop, train and direct staff
Strong knowledge of and skills with health care information systems, report writing, spreadsheets and word processing systems
Proven ability and skills adjusting to rapidly changing projects and priorities and in rapidly identifying and understanding problems situations and using the necessary analytical, delegation and communication skills to resolve them

Care Management Coordinator Resume Examples & Samples

Process phone and fax authorization requests for medical services from physicians and hospitals (providers) in an efficient, accurate, and customer focused manner in accordance with established criteria sets and established Prominence Health benefits and requirements
Verify eligibility and benefits for services requested by Primary Care and Specialty Physicians from Health Plan guidelines and maintains documentation in system
Proficiently logs all telephone inquiries from providers and members regarding problems, benefits inquiries, referral and authorization status or copies of letters and data
Determine when to refer to Care Management Director for higher level of review when indicated by request
Maintain tracking and monitoring of assigned referrals at all levels of review for instant retrieval
Perform daily computer entry of referral information following established protocols and guidelines for monitoring quality and timeliness of entry with minimal errors
Provides accurate and timely daily Activity Reports as required in Department Policies for production information
Meet production standards for performance as set by supervisor for the department
Coordinate and maintain a system for receiving, processing, and resolving provider reconsiderations in accordance with all applicable contract provisions, plan policies, procedures, rules and regulations and coordinate with Claims and other departments to ensure timely resolution
Respond to daily questions from delegates, medical offices, hospitals, skilled nursing facilities, and home health agencies about the necessary steps of the medical referral and authorization process, benefit interpretations, and claims processing
Initiates communication with delegated groups, physicians, their office staff, and outside providers as needed to gather information for processing referrals and authorizing services to Managed Care patients
Support Concurrent Review and Case Management as needed
Assist in the development and implementation of job specific policy and procedures pertaining to but not limited to accurate data entry, rapid telephone response, provider reconsiderations, and following guidelines for authorizations
Review current and proposed Federal, State, CMS, and NCQA standards that regulate Utilization Management activity
Assist with and conduct review of retrospective referrals and/or claims to verify all authorized services were performed as specified
Assist in preparing and submitting projects, reports, or assignments as needed to meet department initiatives and/or objectives
1-2 years demonstrated working knowledge of Managed Care products preferred
Medicare experience preferred
Experience in lieu of above qualifications will be considered

Care Management Coordinator Supervisor Resume Examples & Samples

Establish & oversee the CMC team guidelines in support of established Care Management standards
Develop and manage policies and procedures, workflows, training and sharing of best practices
Serve as point of escalation for issues that the CMCs are unable to resolve
Assure timely and accurate communication to the CMCs on updates and changes related to processes, workflows and systems such as QNXT, in order to improve standardization of the CMC functions and information sharing through cross-functional knowledge sharing
Develop, and maintain a thorough knowledge of the referral, prior authorization, appeals and other related functions as well as emerging technologies and make recommendations for improvements to enhance the Provider & Member experience
Provide day to day management of the team including internal audits and coaching the team as appropriate
Work with Information Technology (IT) to ensure automation and efficiencies around telephone, fax and other related systems utilized by the Coordinators. Review and interpret the impact of new applications and/or updates
Participate in implementation of new technology and systems related to the prior authorization process
Support corporate quality improvement processes and ensure compliance with regulatory, accreditation, and health plan standards, including participation with the annual CMS data validation audit and other audit needs as they arise
Represent CMCs in cross-functional meetings and committees when establishing and analyzing new processes. Communicate with other departments and provide technical support to staff in order to increase understanding, distribute information and resolve prior authorization related issues
Prepare routine daily reports and dashboards related to inventory, TAT, resources and challenges. Track and trend results and complete root cause analysis in order to identify potential issues, create controls for use in training and development and achieve continuous improvement
Serve as the department expert for the Plan benefits, standards, tools and systems utilized by the CMCs Customer Service to ensure timely completion of a prior authorization request
Support the daily CMC functions by acting in capacity as a CMC
Foster strong professional working relationships with others in the company, delegates and external agencies to aid in the implementation of cross-functional cooperation and improvement of interdepartmental processes
Work with Medical Directors, VP of Quality and Care Management, Manager of Care Management, A&G team, Claims and other cross functional teams
Manage corporate compliance within the CMC team to ensure compliance for the department
Adhere to all company compliance standards and maintain confidentiality of member, physician and employee information
Maintains accurate records of all communications
High School education required
Five (5) years’ experience in a provider setting and/or health plan operations/administration preferred
Minimum of two years of managerial/supervisory experience
Exceptional people management skills including the ability to build and motivate teams and maximize performance
Strong problem-solving skills, project management and negotiation skills and the ability to multi-task in an effective and organized manner
Familiarity and understanding of benefits and claims payment systems, enrollment processes, clinical operations, claims, financial funding and capitation models, reporting and their respective interfaces
Experience working in Medicare, Medicare Managed Care, and Medical Terminology. Managed health care experience

RN Utilization Review, Care Management, PRN Resume Examples & Samples

Performs initial, concurrent and retrospective reviews on all inpatient, facility and appropriate home health services
Ensures appropriate placement and monitors level and quality of care
In conjunction with, and under the supervision of physicians, evaluates and provides feed-
Addresses care issues with Manager of Care Management Physician Advisor and Chief Medical Officer/Medical Director as appropriate
Coordinates identification and reporting of potential high dollar/utilization cases to reinsurer and finance department for appropriate reserve allocation
Consults with physicians, health care providers and outside agencies regarding continued care/treatment or hospitalization
Clarifies health plan medical benefits, policies and procedures for members, physicians, medical office staff, contract providers, and outside agencies
Review per diem patients daily for medical necessity to ensure reimbursement
Responsible for the early identification and assessment of members for potential inclusion in a comprehensive case management program. Refers members for case Management accordingly
Actively participates in the discussion and notification processes that result from the clinical utilization reviews with the facilities
Reviews any service denials and gathers necessary supporting documentation from chart audits and follows up according to procedures
Assists in the identification and reporting of Potential Quality of Care concerns
Responsible for assuring these issues are reported to the Care Management Manager
Provides backup for Case Manager
Work as an interdisciplinary team member within Divisional Care Management departments
Understands and self-manages to support facility/CIN-level success goals, including improvements in quality, cost of care and member experience for the facility/CIN’s population
Identifies opportunities for improvement (at individual, clinic and facility/CIN levels) and actively works with healthcare and facility/CIN team to correct or improve results

Lvn-population Care Management Resume Examples & Samples

Prepare and administer medications as directed by physician order following established protocols
Identify and arrange for equipment needing repair
One (1) year of recent (within the last three (3) years) experience as a LVN in an acute/outpatient setting
Current Basic Life Support card
Bilingual (English/Spanish) Level II required
Customer service oriented and able to multi-task multiple priorities
Health Connect functionality (ordering of tests/procedures, scheduling appointments, thorough chart review), Proactive Office Encounter (POE) skills, and Ambulatory Care experience are highly preferred
High quality documentation and productivity of encounters will be monitored as an expectation of the employee hired, in addition to weekly review of work status with the lead/supervisor/manager

Care Management Consultant Resume Examples & Samples

Acts as outward-facing, dedicated resource for assigned accounts, typically with direct client contact (not call center) and large or complex accounts
Builds relationships with employer/group clients (not individual members) and serves as the primary point of contact for overall and day-to-day service delivery
Represents client internally and coordinates with other functions to implement client systems, complete projects, and address ongoing service needs
This function includes employees who are in dedicated on-site service roles
Jobs in this function may work closely with sales on renewals and upselling, but incumbents do not have specific sales goal accountability or primary responsibility to close sales
Account Management jobs focused primarily on relationship and service management belong in this family; jobs with significant sales responsibilities or sales-related incentives (including 'OTH' plans) belong in a sales band
Bachelor's Degree (or higher) or a High School Diploma/GED with 10+ years working within the Insurance Industry
Proficient in Report Analysis and plan recommendations
Must be willing to travel to customer meetings (travel will be approximately 35%)
Familiar with Medical Management or Medical Terminology
Comfortable speaking in front of an audience

Director HBH Care Management Resume Examples & Samples

Design and structure team for management of HBH Care Management and steps required to gain consent through graduation
Collaborate on the development of Trend Benders; manage team to meet or exceed Trend Bender commitments for each line of business
Direct supervision of HBH Clinical Managers and oversight of these manager’s teams including personnel hiring, performance monitoring, disciplinary actions, performance reviews, etc
Run weekly and monthly staff meetings (including matrix partners) to assure all associates are aligned on goals and progress
Partner with HBH Medical Directors to design and improve clinical outcomes and program efficiency for all programs
Partner with other Humana matrix partners to encourage appropriate referral into HBH care management
Design and implement integrated medical-behavioral co-management programs with other Humana clinical programs; oversee and steer HBH interests in the Clinical Optimization pilots
Explore and design a chronic care management program for chronic serious mental illness and addiction issues (in conjunction with Medical Directors)
Oversee daily, weekly and monthly metrics and assure we meet targets by line of business
Partner with other Clinical Directors to design and implement field care management in markets and within the MSOs
Implement policies and procedures as directed by the HBH Medical Directors
Assure compliance with accrediting bodies, CMS and Humana standards
Serve as a clinical representative to Humana and external clients to promote our services
Strong knowledge of behavioral health clinical practices
Seasoned healthcare executive to provide leadership, mentoring and guidance to the team
Strong project management skills to track new initiatives and projects
Strong analytic skills to understand operational and clinical metrics
Excellent execution/implementation skills to assure follow-up and completion of work
Excellent collaboration skills with HBH management, peers, matrix partners and associates
Ability to create strong Engagement with employees; ability to inspire staff toward our vision
Open mindedness. Examples include openness toward alternative modalities for care such as telemedicine; or, providing embedded clinicians into our owned and JV physician partners
Understands and lives Humana values
Understanding and engaging in risk management procedures and practices
Advanced graduate degree in psychiatric nursing, psychology, social work or counseling with appropriate licensure
Prior experience in establishing and running behavioral Care Management programs
Experience in a wide variety of care management programs including models of behavior change, Severe Mental illness, Substance Abuse Disorders, Autism Spectrum Disorders, Traumatic Brain Injury, and Post Traumatic Stress Disorder, Eating Disorders, etc

Associate Director Care Management Resume Examples & Samples

Implementation and oversight of all clinical management functions for individuals receiving care management (level one and two) program, including but not limited to: assessment, care coordination, interaction with state agencies and community organizations as related to care plan coordination, participant and caregiver education, and oversight of multi - disciplinary care conferences
Experience working with diverse groups of members, state / federal regulators, and stakeholders
5+ years of extensive experience in leadership and management

Mgr, Care Management Resume Examples & Samples

Partners and collaborates with other departments cross-functionally regarding care management and/or Health Service initiatives
Manages and resolves e-mails and escalated phone issues in response to provider, staff, and other departmental requests
Directs work assignments, measures results, and initiates personnel actions as required
Develops, implements, and manages process improvement initiatives
Applies a comprehensive knowledge of Care Management to the completion of assignments
Required - A Bachelor's Degree in Nursing or Health Admnistration
Required - 5+ years of experience in Current care/case management
Required - 3+ years of experience in Managed Care
Required - 1+ year of management experience
Demonstrated time management and priority setting skills
Ability to drive multiple projects
Ability to create, review and interpret treatment plans Ability to create, review and interpret treatment plans
Demonstrated negotiation skills
Advanced knowledge of healthcare delivery
Advanced ability to effectively present information and respond to questions from families, members, and providers
Advanced ability to effectively present information and respond to questions from peers and management
Required - Microsoft Outlook Intermediate to high level efficiency in Microsoft Office including Outlook, Word and Excel
Required - Microsoft Word
Required - Microsoft Excel
Required - Healthcare Management Systems (Generic) Intermediate to high level efficiency in Visio preferred
Preferred - Microsoft Visio

Care Management Program Analyst Resume Examples & Samples

Provides support to Medicaid Members actively enrolled in the Care Management Program through assisting in the coordination of their healthcare within the parameters of the program
Administers the program in accordance with applicable state and federal regulations governing member placement into the program
Supports program through data analysis and statistical evaluations of member Medicaid usage
Builds placement documents and standardized reports with a focus on quality
Updates and maintains accurate logging and data entry associated with program administration
Responds to escalations concerning members enrolled in the Care Management Program
Discusses proposed decisions with SUR team members, inter-departmental personnel, providers, and state or federal agencies as required
Coordinates with SUR team members to propose and implement improvements to program operations
Builds solid working relationships with Medicaid providers as a representative of the Care Management Program
Bachelor's degree or equivalent combination of work experience/education (Healthcare, Business Admin, RN/LPN, Medical Coding, Information Systems); plus
Intermediate knowledge of Microsoft Office products (Word, Excel, Access)
Basic knowledge of data analysis, manipulation techniques, and statistics
Basic knowledge of database principles
Excellent analytical, problem solving, verbal and written communication skills (cover letter will be used as a writing sample, please bring a second writing sample to the interview)
Demonstrated organizational skills with ability to multi-task and follow up
Ability to adhere to tight schedules and target dates

Care Management Assistant Resume Examples & Samples

One to two years of prior care management experience preferred
Acute care hospital experience preferred
Medical terminology course preferred
Ability to deal with public and professionals in high stress situations
Able to self-motivate and prioritize a variety of duties
Highly proficient in computer applications

Care Management Specialist Resume Examples & Samples

Knowledge of medical terminology required
Knowledge of various software applications., ie Excel, Access, Power point preferred
Excellent communication, customer service, interpersonal and organizational skills
Must be able to work under considerable stress, using tact and diplomacy
Must demonstrate the ability to work independently, problem solve, and be able to resolve conflict in an assertive manner

Manager, Comprehensive Care Management Resume Examples & Samples

3+ years previous Managed Care experience
Masters in a related field required
MSN, MBA, MHA, MPH, MSSW preferred
Progressive management experience

Director, Care Management Resume Examples & Samples

Provide independent on-site assistance in developing and implementing care management initiatives to achieve overall program goals
Closely monitors and analyzes outpatient reports and identifies trends. Develop and execute solutions to improve all resource management
Facilitates team process problem resolution using HCP administration, Medical Directors, Contracting, Risk Management, Behavioral Health and health plans regarding complex patient issues. Implements the results of the collaboration process
Monitors all high risk/high cost patients in regard to care delivery, referrals, etc
Identifies opportunities for the development of new care management approaches
Provides supervision and guidance to staff reporting to the position
Conducts monthly staff meetings including utilization management review outcome measurements (ADK, re-admit rate, LOS in SNF) and identification of training/educational opportunities
Identifies, develops and oversees the educational needs of Care Management staff, providers and others. This can include an extensive orientation program, cross-training and proactive approach to case management
Ensure that all operational processes that are implemented are in compliance with all federal, state and accrediting body standards
Demonstrates, by action and attitude, the standard of high staff and physician satisfaction, treating staff and physicians with respect
Experience managing operating departments in hospital/health systems
Experience providing strategic leadership, managing teams and leading projects required
Knowledge of CM regulations that fall under CMS, NCQA, DMHC and other applicable state and accreditation standards
Ability to develop and maintain effective working relationships with other teammates, patients and the general public
Excellent verbal, written and interpersonal communication skills
Ability to relate to culturally diverse patients and community
Ability to develop positive interaction with patients, families, physicians, administrators and teammates in order to effectively care for the patient
Ability to build strong relationships across multiple functional lanes

Care Management Coordinator Resume Examples & Samples

Evaluate proposed plans of treatment, as defined in the precertification requirements of the group plan
Using the medical criteria of InterQual and/or Medical Policy, establish the need for inpatient, continued stay and length of stay, procedures and ancillary services
Directs the delivery of care to the most appropriate setting, while maintaining quality
Reports potential utilization issues or trends to designated manager or senior clinical nurse
Strong problem solving and critical thinking abilities
Proficiency utilizing Microsoft Word, Outlook, Excel, Access, SharePoint, and Adobe programs
Excellent organizational planning and prioritizing skills
Ability to work independently and provide positive resolution of complex medical and interpersonal challenges
Highly professional interpersonal skills for internal and external contacts, particularly in situations where medical evaluations are in conflict with treating providers proposed treatment plans
Comfortable with new ideas and methods; creates and acts on new opportunities; is flexible and adaptable
Builds team spirit and interdepartmental rapport, using effective problem solving and motivational strategy
Performs additional job-related duties as assigned
This role as the potential to WFH after 6 - 12 months*

Manager, Reg Care Management Resume Examples & Samples

Oversees and monitors patient eligibility, financial contract accountability and health plan benefit determination for each patient referral. Facilitates resolution on areas of conflict
Designs, implements and facilitates data and statistical collection including outcome and quality of care information
Monitors all high risk/high cost patients in regard to care delivery, referrals, contracting, etc. Monitors provider referral patterns for appropriate utilization of specialty and ancillary services
Conducts monthly staff meetings including utilization management review outcome measurements and identification of training/educational opportunities
Contributes to the Care Management business plan and budget process along with the Vice President/Director, Regional Care Management
Knowledge of medical/nursing standards of care
Ability to effectively collaborate with physicians, patients/families and ancillary staff

Care Management Lead-careallies Resume Examples & Samples

Deep healthcare consulting /managed care industry experience – minimum of 5 years in a relevant field
Extensive knowledge of the healthcare industry (in particular Medicare and Medicaid products and business models) as well as a deep understanding of managed care, care management, disease management and health advocacy
Deep domain knowledge of Medicare Advantage product development and support required. Specialized knowledge of Medicaid to Medicare expansion is preferred
Deep knowledge of Medicare, Medicaid and other government-related health programs, products and services. Strong knowledge of how Cigna and its key competitors operates
Current or recent clinical operation leadership experience in a related setting preferred
Ability (and desire) to dive deep into data, including assisting in writing business rules to extract best opportunities for each strategic campaign
Experience as a team leader or key team member involving complex projects, pilots or new customized solution resulting in successful execution to plans
Clinical operation experience with key leadership responsibilities involving complex projects across multiple matrix organization
Strong ROI evaluation and management
Operating cost modeling and financial analytics and oversight
Innovative and open to new ideas in a focused, intense and growth oriented environment
Strong analytic thinking and able to generate ideas from industry studies, reports, research and able to support root cause analysis to generate new innovative ideas and concepts
Demonstrated experience and exceptional ability to work productively in a matrix management environment across geography, departments and position level
Previous experience as a clinical operation implementation team leader or key team member involving complex projects, pilots or new customized solution resulting in successful execution to plans
Action oriented, works with a sense of urgency and takes responsibility to execute to meet aggressive timelines
Strong communication and presentation skills and an ability to influence at multiple organizational levels
Strong interpersonal, networking and negotiations skills
Strong motivator and team player- able to lead and delegate responsibilities as needed

Medical Director, Complex Care Management Resume Examples & Samples

Routinely meet with currently collaborating PCP’s
Collaborate with business development team to identify potential SNFs / Provider Groups with new membership opportunities
Assist in quality of care concern case reviews and corrective action plans
Fulfill requirements for SNP Model of Care; State; and Federal regulations
Lead market review and develop education and operational plans to address pharmacy, acute hospitalization, skilled SNF services, DME, and physician medical expense
Provide leadership accountability for ensuring accuracy of all documentation and coding
Educate NP / PA staff in use of coding tools and documentation requirements
20-30% day travel within DFW market with occasional travel to Houston market
MD or DO in State of Texas
ABMS Board Certified in: Internal Medicine, Family Practice, Geriatrics or Hospice/ Palliative Care
Minimum of 5 years of geriatric and long-term care experience
Demonstrated experience working with and educating NP’s and PA’s
Inpatient / SNF utilization metrics and bed day management
Financial Reports: Revenue; Expenses; Contribution Margin; Budgeting & Forecasting; BCR; IOI
Working knowledge of EMR structures

Care Management Director Resume Examples & Samples

Plans, directs and supervises all aspects of Care Management. Leads, develops and mentors Care Management Department Programs throughout the continuum of care delivery
Facilitates growth and development of the Care Management Program consistent with corporate mission, vision and values and models organizational values
Collaborates with the medical staff on resource utilization issues, and compliance with payer and utilization-related private contracts, public programs contracts and applicable federal and state regulatory mandates. Ensures programs/services provide cost-effective use of patient care resources and care delivery at the most appropriate level. Collaborates across departments on projects that supports vision and mission for care management and Adventist Health
Analyzes and monitors quality, customer service, cost reimbursement and utilization trends that support organizational financial performance. Manages day to day operational budget. Ensures revenue, expenses, FTE’s meet budget, prepares and submits budget related reports. Utilizes data to drive decisions, plan and implement performance improvement strategies for care management and recommends action plans for resolution. Designs overall department structure, staffing is appropriate and cost-effective, technology use is maximized and staff and operational performance standards are met or exceeded
Develops staff performance plans, provides regular performance feedback, manages direct reports and performs personnel actions in accordance with policy & procedure. Responsible for oversight of education of staff to meet industry standards by promoting interdisciplinary collaboration, fostering team work and championing service excellence
Responsible for oversight of education of staff to meet industry standards by promoting interdisciplinary collaboration. Monitors daily Interdisciplinary Rounds which fosters team work and champions service excellence
Oversees Policy & Procedures creation and implementation in compliance with all lines of business, and regulatory agencies
Builds and maintains external relationships with key community and business partners
Ability to maintain high level confidentiality
Strong leadership and management skills including ability to mentor and develop staff
Excellent communication and negotiating skills
Program development skills
Effective analytical, system redesign skills
Current health care professional licensure as a RN OR LCSW
Current/Minimum of 5 years of utilization review/case management experience or social work experience in an in-patient acute care setting
Must maintain current professional licensure in nursing or professional field of certification
Must currently reside in or be willing to relocate to the Napa, CA or Clearlake, CA area
5 years of experience in discharge planning from a hospital

Manager, Reg Care Management Resume Examples & Samples

Add Job Functions for this manager role
Over 3-5 years and up to and including 5 years of management experience
Interviewing and interpersonal skills

Care Management SME Resume Examples & Samples

At least 3 years of experience as a healthcare consultant with PCMH - Patient Centered Medical Home expertise as well as Case Management/resource management, care protocols, care gaps, and clinical workflow
Bachelor's Degree in Nursing, Healthcare Administration, or related field
At least 1 year of experience with software implementation, or knowledge of Explorys, or Watson Care Manger

Mgr / CHS Care Management Resume Examples & Samples

Oversees the development of department specific goals and objectives
Ensures implementation of strategic and process changes designed to achieve outlined goals/objectives
Ensures Standards for staff qualifications and competencies, continuing education, and staffing levels are maintained. Coach and mentor staff to ensure the achievement of department goals and objectives
Provides leadership, mentoring, and coaching to direct reports. Provides leadership and support for shared governance model
Promotes effective communication and collaboration among all members of the CHS Care Management team, as well as community partners and providers across the continuum
Participates in the initiation, development, and maintenance of clinical pathways/protocols and other population-based programs, facilitating collaboration and consensus of multidisciplinary teams throughout the process
Identifies, analyzes, and evaluates the effect of clinical care coordination on quality outcomes, fiscal parameters, customer satisfaction, and system operations and implements strategies to resolve system, performance, and patient variances. Utilizes data systems to monitor process improvement and resource utilization
Formulates, implements, and evaluates strategies for specialized staff education as it relates to patient care, case management and/or clinical pathways/protocols
Demonstrates leadership in the professional practice of nursing evaluating his or her own nursing practice in relation to professional practice standards and guidelines, relevant statues, rules and regulations

Care Management Coordinator Resume Examples & Samples

Performs complex triage of high-volume referrals and channels to the appropriate Care Managers
Decreases the workload of LVN/RN, Care Manager by authorizing requests for service following the preferred provider and/or extended provider listings to obtain difficult benefit interpretations from health plans for Care Management Coordinators 1 and 2 and LVN/RN, Care Manager
Performs high-level critical thinking for re-direction of inappropriate referrals
Assists Supervisor in mentoring and overseeing data entry for IRR and ensuring adherence to PPL, PRL and IMCS processes
Interfaces with acute care facilities and skilled nursing facilities with multiple contractual agreements to ensure proper inpatient/outpatient authorizations
Utilizes applicable facility-based software to obtain admission information daily to verify eligibility and benefits and to ensure containment of costs
Informs RN, Care Manager of admission, eligibility and benefits problems
Monitors admission of patients from other IPA/regions and notifies inpatient or OOA Care Manager of admission so that hospitalist can be assigned to care of patient
Maintains accurate daily census, admission and discharge data for review by Regional Manager to ensure appropriate use of Care Management staffing
Monitors length of stay for exhaustion of SNF benefits
Updates day surgery authorizations as hospital records are received
Interfaces with hospital Business Office to obtain retro reviews on patients inaccurately coded upon admission or for hardcopy emergency room admission authorizations
Assists Regional Manager with Bed Day Error Report by communicating with Care Manager to assure timely level of care and D/C data entry
Monitors HCP daily census to check for errors in data entry
Enters into IDX all DME and HH requests for service from acute and SNF Care Management
Facilitates exchange of information between all levels of Care Managers to ensure continuity of care
Assists Manager, Care Management in communications with Care Managers
Works on special projects for Manager, Care Management
Knowledge of medical terminology, CPT and ICD-9 coding
Knowledge of IPA/group internal processes and contractual agreements
Working knowledge of HMO/managed care/health plan
Ability to adhere to multi-contract language
Excellent communication, organization and customer service skills

Director, Care Management & Quality Resume Examples & Samples

Oversee a team of analysts supporting population health management, risk adjustment and quality strategies (e.g. Stars, HEDIS, Pay for Performance contracts, MACRA)
Act as a subject matter expert around Clinical and Quality Analytics and the development of performance measurement tools
Collaborate in an inter-disciplinary team to develop client outcomes in a value-based care environment
MS degree or PhD in Health Related Field (Biostatistics, Health Informatics, Health Services Research etc…)
Subject matter expert in the area of Clinical and Quality Analytics
10+ years health care background with understanding of claims and membership data
8+ years working with a provider or health plan in the area of care management and quality
Strong familiarity with EMR data and systems
Experience and credibility interacting with c-level executives, including medical directors
Experience managing an analytical team
Experience in healthcare care program evaluation
Experience with understanding value-based contracts (e.g., P4P, shared savings, ACO, bundled payments, etc…)
Experience with governmental and commercial payer quality programs
Familiarity with clinical, claims and administrative data in the healthcare environment
Must live in Nashville, TN or surrounding area
Ability to travel up to 25%
Strong background with provider health systems preferred
Expertise with the Symmetry, Impact and Optum One Suite of Products

Manager, Comprehensive Care Management Resume Examples & Samples

Master’s Degree in Social Work or Bachelor’s Degree in Healthcare Required
LMSW, LMSW-AP, LCSW or RN License Required
5+ Years’ Experience Required

Mgr, Care Management Resume Examples & Samples

Required A Bachelor's Degree in Nursing or Health Admnistration
Required 5+ years of experience in Current care/case management
Required Intermediate Healthcare Management Systems (Generic) Intermediate to high level efficiency in Visio preferred

Director of Care Management Resume Examples & Samples

High-risk program
Transition of care programs
Readmission reduction programs
House calls and other post-hospitalization solutions
Best practice comprehensive health assessment programs
Reporting and analytics
Provide supervision and guidance to team reporting to the position, including conducting regular staff meetings, training and education as required
Closely monitor and analyze reports to identify trends
Develop and execute solutions to improve processes
Identify opportunities for the development of new care management approaches
Identify, develop and oversee the educational needs of care management team, including extensive orientation program, cross-training and proactive approach to case management
Ensure all operational processes are implemented as required to be in compliance with federal, state and accrediting body standards
Perform additional duties as assigned
Commitment to and role model of DaVita’s values of Service Excellence, Integrity, Team, Continuous Improvement, Accountability, Fulfillment and Fun with ability to demonstrate those positively and proactively to patients, teammates, management, physicians, and/or vendors in every day performance and interactions
Visionary with ability to plan and execute projects that impact mission, goals and objectives
Demonstrated proficiency in consultative skills when addressing complex inquiries from clients, vendors and customers
Exceptional client relationship management and people skills – a relationship builder
Entrepreneurial mindset in cultivating and maintaining internal and external partnerships
Proven strong leadership skills and the ability to collaborate across functions and with all levels of the organization and with outside physicians and potential business partners
Analytical thinker with demonstrated ability to perform root cause analysis, prepare and implement action plans, and lead initiatives
Demonstrated strengths in strategic planning teambuilding, leadership, and management skills
Strong interpersonal and customer service skills
Demonstrated ability to manage and influence people, processes, and customer relationships
Ability to recognize interdependencies of process and how changes impact overall integration efforts
Excellent presentation, communication (written and verbal), and negotiation skills
Highly developed persuasion and influence skills; able to influence without authority
Demonstrated ability to create, refine and manage new business processes; demonstrated business expertise
Demonstrated ability to perform cost-benefit analyses to drive decision-making, and skill in explaining the results to teammates with no financial background
Demonstrated ability to work effectively at both detail and big-picture levels and to drive projects forward
Strong multi-tasking capabilities
Supervisory experience demonstrating willingness, desire, and ability to supervise with aptitude for coaching, mentoring, training, and developing teammate performance and skills to foster a positive work environment required
Demonstrated ability to lead and motivate teammates
Ability and willingness to maintain open and clear communication with staff
Ability to give and receive thoughtful feedback
Ability to delegate appropriately
Ability to thrive in an environment of high ambiguity and autonomy; exceptional flexibility and ability to manage multiple projects, deadlines and multiple priorities in a fast-paced, ever changing and evolving work environment with shifting time frames
Ability to maximize resources to accomplish all key metrics
Current RN License Pennsylvania required
5+ years’ experience in healthcare, working with providers and/or payers at a management level required
Bachelor’s degree from a four-year college and/or a professional certification requiring formal education beyond a two-year college required
Experience managing operating departments in payers, hospitals, or health systems preferred

RNP, / PA, Depression Care Management Resume Examples & Samples

Collect subjective data (obtain history). Collect objective data (perform a physical exam). Develop an assessment (diagnosis). Develop and implement a management plan. Facilitate the referral of patients to the appropriate health facilities, agencies and resources within the community. Order pharmacologic interventions. Develop and implement an educational plan. Plan for appropriate follow-up care. Consistently supports compliance and the Principles of Responsibility (Kaiser Permanente's Code of Conduct) by maintaining the privacy and confidentiality of information, protecting the assets of the organization, acting with ethics and integrity, reporting non-compliance, and adhering to applicable federal, state and local laws and regulations, accreditation and licenser requirements (if applicable), and Kaiser Permanente's policies and procedures
At least one year recent experience in mental Health/Depression
Experience and extensive knowledge of current psychotropic medications, mange Depression
Ability to screen for Depression and assess suicidality
Must have DEA license, BCLS, National providers License, ANCC Certificates

Director, Care Management DV Resume Examples & Samples

Selects, trains/orients, and assigns department staff (either directly or through subordinate supervisor). Develops standards of performance, evaluates performance, and initiates or makes recommendations for personnel actions
Develops department goals and objectives, and establishes and implements policies and procedures for department operations
Develops and recommends department operating budget and ensures that department operates within budget
Directs the preparation and maintenance of department reports. Prepares periodic reports for senior management, as required
Develops and implements the performance improvement program for Care Management
Assures compliance with federal and state law and accrediting and licensing agencies as appropriate to department
Integrates departmental services with the organization’s primary functions and coordinates with other department/services in a manner which fosters a collaborative environment or teamwork within the department and with other departments/services
Ensures and role models the delivery of excellent customer service
Directs the care management team’s collaboration with all patient points-of-entry departments, Business Office and others involved in patient care and reimbursement, to ensure appropriateness of patient placement status and the timely and accurate completion of reimbursement requirements for the organization
Evaluates departmental compliance for correct utilization of standardized medical staff approved criteria to determine appropriateness of placement status of patients (inter-rater reliability)
Directs CM staff collaboration with involved practitioners and organizational staff in the continued stay review process to ensure ongoing appropriate utilization of organizational resources, medical record documentation, and regulatory compliance
Plans and supervises all aspects of the Care Management program including utilization/financial management, clinical care coordination, psychosocial support and coordination, transition planning, customer service excellence and quality improvement
Develops and maintains positive relationships with payers to include practices and policies of external review, concurrent review, denial management and the appeals process
Creates strategies for Care Managers to enhance efforts for maximizing patient/family outcomes for safe transition back into the community
Facilitates growth and development of the Care Management program consistent with system-wide philosophy and in response to the dynamic natures of the health care environment through benchmarking for best practices, networking, quality improvement, research and other activities as needed
Supervises Care Management staff compliance with federal and state law and accrediting and licensing agencies as appropriate to the Care Management department
Serves as expert in the fields of care management and managed care, interpreting and communicating processes as changes in these fields to staff, physicians, and the community
Ensures discharge planning process is compliant with Center for Medicare and Medicaid Services Conditions of Participation and the Joint Commission guidelines and standards
Ensures departmental policies, procedures and job descriptions are reviewed at a minimum of annually and whenever there is an accrediting or regulatory body change. Ensures these documents are compliant with all related regulatory and accrediting body standards
Ensures at least annual review or organizational utilization management plan and ongoing completion of utilization management dashboard and utilization management compliance reports and corrective action plans as needed
Enhances professional growth and development through participation in educational programs, current literature, inservice meetings and professional conferences
Participates and attends meetings and inservices as required and/or assigned
Three years of experience in utilization management, case/care
Five years of experience in utilization management, case
Licensed to practice in the State of Michigan for specific scope of
Analytical ability and comprehensive knowledge base to identify

Care Management Mgr Resume Examples & Samples

Develops and oversees standardized policy implementation with regards to the Molina integrated care management model
Accepts specific assignments for policy and program development and implementation for key initiatives within the integrated care management model (assessments, care plans, interdisciplinary care team mtgs, long term care services, model of care, NCQA requirements, curriculum development, health plan standardization, liaison to other departments, UM, BH, Pharmacy)
Manages and monitors all Care Management team clinical and non-clinical team activities to facilitate integrated proactive case management
Participates in committees, task forces, work groups and multidisciplinary teams as needed
Performs and promotes interdepartmental integration and collaboration to enhance case management services including, Behavioral Health and Long Term Care for Molina members
Collaborates with and keeps the Dtr Care Management appraised of operational issues, staffing, resources, system and program needs and presents resolution action plan for identified issues
Works with the Dtr Care Management to ensure adequate staffing and service levels, and maintains customer satisfaction by implementing and monitoring staff productivity and performance indicators
Completes quality audit reviews for corporate Case Management policy and program implementation staff
Oversees staff activities to ensure compliance with state and federal regulatory and accrediting standards
Maintains professional relationships and facilitates open and timely communication between team members, medical directors, other Molina department employees and external customers.Under the direction of the Director of Care Management, manages and oversees Molina corporate policy and program implementation of Molina standardized Integrated Care Management processes focused on assisting Molina Healthcare members with their overall health care needs to achieve optimal clinical, financial and quality of life outcomes. Collaborates with the Corporate Dtr Care Management to provide effective, integrated, comprehensive, multidisciplinary case management. Evaluates the services provided and outcomes achieved by the team and recommends enhancements and/or improvements for programs and staff development to ensure consistent cost effectiveness and compliance with all state and federal regulations and accrediting guidelines. Demonstrated ability to communicate, problem solve, and work effectively with people
Excellent organizational skill with the ability to manage multiple priorities
Knowledge of applicable state, and federal regulations

Care Management Resume Examples & Samples

Completes administrative functions associated with Care Management tasks
Assists patients with external resources at the direction of the Care Management nurse
Utilizes various data sources and enters data in JSA programs and spreadsheets
Performs general clerical duties such as typing correspondence, creating or updating spreadsheets, photocopying, faxing, and compiling data and other materials or other duties as required
Obtains necessary patient information from clinical centers in order to assist with discharge process
Obtains medical records and faxes to Scanning department for entry into EHR
Enters referral requests
Assists with scheduling post discharge follow up appointments with PCP when requested
Medical Assistant experience, RMA/CMA Preferred
Experience in a health care related setting
Possess excellent communication and organizational skills with the ability to multi-task, set priorities, and meet deadlines
Must be computer literate and possess the ability to master different medical record software programs
Demonstrate exceptional telephone skills
Demonstrated proficiency in Microsoft Office, Email and general computer functions
Proficient in Excel spreadsheets
Must have consistent, punctual, and reliable attendance

Clerk, Care Management Qualcare Resume Examples & Samples

Documents phone stats from previous business day in excel spreadsheet
Sorts and distributes mail for department, including faxes and printer material
Order supplies and copy paper
Distributes mail
Responsible for tracking x-rays and pictures according to policy and procedure
Makes member charts for filing of denials
Runs monthly Hi-Dollar reports for all lines of business and forwards to Director and Manager
Runs monthly ACD reports for all lines of businesses and documents in S drive
Logs time off requests and distributes information as per policy and procedure in daily
Enters a CareStepp authorization regarding medical decisions of Podiatric and Chiropractic Advisors regarding services provided to members and generates letters following policy and procedures
Fulfills needs of UM Department as deemed necessary by Senior Management
Answers phones for the Management team
Assist with additional projects for Supervisors and Management

Care Management Director Resume Examples & Samples

Perform personnel management duties including screening and selection of ur staff, providing department orientation and training, completing performance evaluations and giving feedback to the HR Office
Adhere to hospital's FTE standards and serve as the departments fiscal manager
Conduct admission reviews working with Assessment and Referral to stay abreast of admissions
Prepare and submit appeals to third party payors, effectively coordinating collection of all pertinent data to support the hospital and patients position
Conduct concurrent and extended stay reviews on appropriate day and or specified time
Maintain and update logs of review and maintain other appropriate records of the Utilization Review Department
Remain current on applicable UR trends and regulations and review current policies and procedures for compliance
Serve on the DBHS management team

Care Management Liaison Resume Examples & Samples

Provide support, assistance, and resolution to the eMSM for referral and authorization processing while establishing and maintaining collaborative working relationship with eMSM/MTF referral management associates
Understand and provide support for TRICARE benefit review, and Humana Military medical necessity review requirements
Identify and refer cases to appropriate Humana Military Care Management Programs and Quality Management
Support eMSM and Humana Military Field Operations by attending eMSM meetings as needed
Provide feedback to Regional Manager on issues that may require manager review, assistance and or coordination with other departments, managers or supervisors
Professional Registered Nurse with valid license
Effective relationship management
Bachelor’s degree in health-related field
Two years previous supervisory/management experience
Professional certification in utilization review, case management, or quality management
Three or more years of utilization or case management experience
Use of health and business data and informatics

Director Inpatient Care Management Resume Examples & Samples

Current, unrestricted RN license required
BS or BSN degree a plus
Minimum of 5 years hands on clinical experience including Managed care experience required
3+ years in a management role with focus on Utilization Management required
Knowledge of ACO, HMO, PPO's strongly preferred
Experience with data analysis and accountability preferred
Experience with the utilization of criteria based decision making tools, such as MCG, Interqual or other criteria-based guidelines a plus

Clerk, Care Management Resume Examples & Samples

Handle Authorization loads in to TruCare
Review Claim Error Report
Participate in system Implementations
Runs various reports for all lines of business and forwards to the Management Team
Runs monthly ACD reports for all lines of businesses and documents on Critical Indicator Report
Runs monthly productivity report and enters total authorizations on Critical Indicator report
Runs monthly clean up report for all clients off of Intranet, prints and distributes to Manager
Runs UM Summary Reports off Intranet and distributes to Director
Runs Maternity Reports for all clients, verifies correct data, does mail merge for letters and newborn calendar
Runs Facility Reports off Intranet monthly and distributes to Director
Runs Utilization Review Activity Reports monthly, off Intranet and distributes to Director
Logs time off requests and distributes information as per policy and procedure
Prepares reports and graphs as requested by Senior Management
1-2 years minimum experience in clerical/administrative role, preferably in a healthcare setting

Care Management Specialist Resume Examples & Samples

Ability to communicate pertinent medical information. Knowledge of medical terminology required
Knowledge of various software applications, i.e., Microsoft Office, including Excel and PowerPoint preferred
Must demonstrate an ability to work independently, problem solve, and be able to resolve conflict in an assertive manner

Care Management Discharge Plan Coordinator Resume Examples & Samples

High School Diploma,Certificate,GED, and/or Training and equivalent experience
Ability to develop and maintain good working relationships
Ability to work in a high volume environment while maintaining high quality standards
Strong Analytical and problem solving skills
Excellent written legible and verbal English communication skills required
Ability to manage workload, set priorities, and operate with minimal direct supervision
Ability to handle moderately to highly complex problems or issues in standard and sometimes emergent situations
Secretarial experience, excellent communication skills
Excellent Customer Services Skills
Computer skills with Microsoft Word
Minimum typing speed of 30 WPM

Care Management Applications Specialist Resume Examples & Samples

Work with the Healthcare Application Development team to translate market needs into clearly defined and detailed written product requirements
Review the work of teammates to ensure quality and completeness against the User Story
Provide industry and product support to Sales, Marketing, Professional Services, and Training teams
Actively participate in the Scrum processes used to develop solutions, providing continuous feedback and implementing changes to our development
7- 10+ years of business or consulting experience in the healthcare industry, including
3+ years of experience as a Business Analyst or Product Manager
2+ years of experience in an Agile/Scrum team environmentAdvanced knowledge of utilization management, care management, and/or clinical operations

Mgr / CHS Care Management Resume Examples & Samples

Oversees the development of department specific goals and objectives ensuring alignment with CHS system strategy, vision, mission, and values
Ensures implementation of strategic and process changes designed to achieve outlined goals and objectives
Ensures Standards for staff qualifications and competencies, continuing education, and staffing levels are maintained
Participates in the initiation, development, and maintenance of clinical protocols and other population-based programs, facilitating collaboration and consensus of multidisciplinary teams
Identifies, analyzes, and evaluates the effect of clinical care coordination on quality outcomes, fiscal parameters, customer satisfaction, and system operations and implements strategies to resolve system, performance, and patient variances
Utilizes data systems to monitor process improvement and resource utilization. Formulates, implements, and evaluates strategies for specialized staff education as it relates to patient care, case management and/or clinical pathways or protocols

Licensed Care Management Supervisor Resume Examples & Samples

An active independent clinical licensure (i.e. Registered Nurse, Licensed Clinical Social Worker, OR Licensed Professional Counselor) required
3 - 5 years in clinical area of expertise
Ability to communicate effectively with Providers, Members, Staff and other Leaders both in oral and written formats
Ability to work with people in such a manner as to build high morale and group commitment to goals and objective
Nursing/Registered Nurse
Mental Health/Licensed Clinical Social Worker
Mental Health/Licensed Professional Counselor

Care Management Coordinator Resume Examples & Samples

A Bachelor's degree in Social Work (BSW); a Bachelor's degree with a relevant major (Psychology, Human Services, Healthcare Administration, Sociology) and related professional background; or a Master level clinician with Social Work degree (MSW) required
Ability to support the complexity of members needs including face-to-face visitation required
Ability to travel in the field (~10-25%), personal vehicle, valid drivers license, and proof of insurance is required
Computer proficiency with Microsoft Excel, Word, including navigating multiple systems and keyboarding required
Ability to multitask, prioritize, and effectively adapt to a fast paced changing environment required
2 years experience in behavioral health, social services preferred
Previous service coordination or case management experience preferred
Long term (LT) services and support experience preferred
Waiver experience preferred
LT support for children and special needs children populations preferred
Discharge planning experience preferred
Experience and knowledge required in clinical guidelines, systems and tools i.e., Milliman, Interqual
Bilingual in English and Spanish preferred
Knowledge of community resources and provider networks preferred

Care Management Assistant Resume Examples & Samples

Provides direct customer service and administrative support to the Care Management Department. This includes but is not limited to providing electronic eligibility verification, updating patient demographics, ensuring required referrals and pre-certifications are forwarded to correct Providers in a timely manner
Handles customer/patient inquires that are forwarded to Care Management, referring to internal department resources for appropriate for resolution
Responsible for obtaining “expert” level knowledge of the benefit plans and the contracts with the various insurance plans, Medicare and Medicaid, regarding prior authorization processes, precertification requirements and other functions related to Care Management of patient populations services by ABQ Health Partners, (ABQ HP). This includes staying abreast of insurance plans in the process of being added, deleted or changed
Responsible for compiling Care Management data and coordinating Care Management data reports as required by ABQ HP’s contracted partners and regulatory agencies
Responsible for contacting patients to educate and/or provide communication and follow-up on the Case Management and Disease Management programs relevant to our patients conditions
Cross trains in Clinics as needed to maintain up to date knowledge of Clinic front office, back medical office and Electronic Health Record (e HR) processes to ensure appropriate support of the Care Management functions
Provides additional support and project work within the various Care Management areas of accountability as needed
Required – Three years of related experience in Clinical setting or health plan, demonstrating intermediate skills in Microsoft Excel, and well as experience with electronic medical record systems
Excellent Customer Service skills, demonstrated through written and interpersonal communications. Ability to type and enter efficiently and accurately at 25-30 WPM. Skilled in a variety of MS Office software applications. Knowledge of medical terminology, benefit plans and medical office systems. Ability to work independently and willingness to learn. Ability to multi-task and work under pressure. Attention to detail. Windows navigation skills

VP of Care Management Service Line Resume Examples & Samples

Seasoned clinical leader experienced with business planning, building and ongoing oversite of care management services for Medicare/Medicaid/Commercial lines of business. Individual should have progressive perspectives on next generation care management models that incorporate and take full advantage of EMR data, point of care integration and emerging biometric and advanced predictive analytics
Front end business planning, forecasting and associated business development/sales support, RFP responses, finalist presentations, and ongoing strategic account relationship management. Development of market segment specific Cerner care management services value proposition
Full scope of product/service development responsibilities – market segment and line of business specific service offerings including market competitive pricing, positioning and underlying profitability, including at-risk/gain-sharing contracting parameters
Experience with Electronic Medical Records systems
Strategic thinker with demonstrated leadership skills, including abilities to direct change to meet organizational needs, express concepts clearly both verbally and written, analyze, problem-solve, prioritize quickly and efficiently and function in a team environment
Working knowledge of case management standards of practice based on Case Management Society of America (CMSA) and NCQA Care Management standards
Knowledge of complex medical and mental health conditions and national standards of quality care
Experience with Quality Improvement methodology and techniques such as Six Sigma, Lean, and Institute for Healthcare Improvement (IHI) Model for Improvement, etc
Current market knowledge and leadership experience with care management and population health programs across public and private payers
Travel as needed
Bachelors’ Degree in Health Care Administration, Business Administration, Nursing or other clinically related degree
Registered Nurse or Licensed Social Worker or other relevant clinical credential
At least ten (10) years of healthcare management or managed care experience
At least ten (10) years of Senior Leadership experience
Masters level degree in nursing or other healthcare related field
Certification in Care Management

Coordinator, Care Management Resume Examples & Samples

Discusses and/or educates the patient and family members as appropriate regarding the treatment plan
Works with Provider Relations by communicating office/provider concerns, needs and expectations
Utilizes all sources of available patient information and secure communication methods, including fax, phone, electronic medical record, health information exchange, case/utilization management system, claims systems, data management systems, etc. Serves as a liaison for PCP/PCP office staff and health plans
Maintains courteous, professional posture at all times
Demonstrates behaviors consistent with identified competencies and job requirements (i.e., continuing education, mandatory in-services, safety training, annual TB testing and organizational integrity program)
Maintains appropriate logs identified by the Medical Management department

Director, Outpatient Care Management Resume Examples & Samples

Establishes roles, systems and processes to address needs of various patient populations including health promotion and risk reduction, chronic disease management and complex care coordination
Performs direct administrative functions for assigned department including, but not limited to budget management, staffing levels, and ongoing evaluation of key performance metrics
Leverages available information technology systems and registries for patient identification, stratification, and generation of patient specific care plans
Establishes comprehensive transition of care processes in collaboration with hospital care management, behavioral health, primary and specialty practices, SNF, rehab and home health services
Collaborates with practice providers and leadership to assure delivery of evidence-based care and closure of care gaps
Establishes support systems and tools for patient/family education and engagement
Establishes and monitors care manager caseloads and performance
Assures appropriate staffing levels, training, and competency of ambulatory care management staff
Demonstrates improvement in various payment model performance metrics inclusive of practice star ratings, admissions, readmissions and ED utilization
Facilitates timely patient access to primary and specialty care and other health services as needed
5 – 8 years management experience in a health care organization

Dir Ephc Care Management Resume Examples & Samples

Participate in Assessment of Target Group
Aid in design of solution in collaboration with Client
Define, Source, Interview, Hire*, Onboard, and support Clinical staff
Design and implement workflows and reporting for appropriate patient targeting
Metrics Tracking

Supervisor, Care Management Resume Examples & Samples

Monitors CM documentation for audit purposes
Works with colleagues in identification of quality issues and problem solves who should be notified of issues
Reviews and collects data on readmission review and keeps Medical Management Director notified of potential issues and patterns
Organizes work groups that address on-going quality and process improvement initiatives
Develops, coordinates, and oversees orientation for new CMs
Responsible for ensuring care management policies and procedures are up to date and accurate
Develops new care management policies and procedures on an as needed basis
Demonstrates self-directed learning and participation in continuing education/research to ensure professional growth
Actively promotes and participates in various task forces, teams and committees as well as participating in events representing Select Health Network

Sup, Discharge Care Management Resume Examples & Samples

Supervises a team of Discharge Care Managers who are engaging in telephonic coordination of discharge plans to transition members from an inpatient setting to an appropriate lower level of care, assessing members' clinical and social needs, and developing individualized care plans which will provide a stable and supportive post-acute care environment
Acts as primary contact for escalated calls and/or escalated issues that require additional research or special handling
Monitors associate performance and conducts counseling/corrective action procedures when required. Identifies concerns, brings issues to management's attention and offers suggestions for improvement
Provides significant input to performance evaluations, hiring and termination decisions for associate in work group
Provides training and guidance to new and current Discharge Care Managers regarding policy & procedure, systemic tools, workload and care plan development
Plays an active role in creating, applying and utilizing accepted policies and procedures
Attends company meetings in absences of manager or director
Performs special projects, tasks and/or other duties as assigned
Required An Associate's Degree in Nursing or Graduation from Diploma Nursing School
Preferred A Bachelor's Degree in Nursing or related field
Required 2+ years of experience in current case management
Intermediate Demonstrated time management and priority setting skills

Care Management Specialist Resume Examples & Samples

The Care Management Specialist is responsible for oversight of patients requiring coordination of pre-admission, admission, concurrent case management and discharge activities
Coordination of care activities will span the simple to the very complex including assessment, planning, facilitation, evaluation and advocacy of options and services to meet the patient and family comprehensive health needs while assuring that interventions are in place to prevent avoidable readmissions due to gaps in care coordination. These activities are performed within the context of managing and promoting quality cost-effective outcomes and in alignment with the revenue cycle
Revenue cycle responsibilities include applying utilization management criteria to available and constantly evolving clinical information with assignment of proper legal status, pacing of care coordination activities and facilitating timely and safe discharges to the appropriate level of care
Effective team work skills are critical as the Care Management Specialist will work across clinical providers, facilities, ambulatory services serving as an advocate for the patient and family. Reliable transportation across NorthShore entities required
Current State of Illinois Nursing License required; BSN required
Three years of clinical nursing experience with a broad experience base
Previous experience in utalization management, managed care or chronic disease management highly preferred

Division VP, Care Management Resume Examples & Samples

Supports the development and compliance of Care Management systems through the use of various supporting technological applications to ensure an appropriate level of resident care and timely reimbursement of the care provided
Responsible for the overall management, compliance, leadership, growth and profitability of assigned programs within the division/district
Develops and provides monthly, quarterly, and annual reports that analyze available clinical and financial data that is generated internally and through external sources to identify trends, variances, practice pattern changes, opportunities for change, etc
Uses standardized reports that include analysis and opportunity for discussion, strategizing, planning, implementation, monitoring and action planning
Develops and implements training strategies with the Interdisciplinary Field Support for all payor types including PPS, Managed Care and State Medicaid Case Mix reimbursement
Develops, implements, monitors and promotes care management systems, models, services, processes and tools at all levels of the organization to assure delivery of quality of care to residents
Participates in CMS and State initiatives as related to nursing facility assessment and reimbursement systems
Provides support to Care Management and teams for clinical reimbursement strategies, systems implementation, training and team development
Manages, monitors and supports all operational, administrative, clinical, and fiscal activities of assigned programs and services to insure quality and consistency with company standards. This includes education and training of all Division, District and facility team members
Directly responsible for ensuring that the quality and appropriateness of patient care/care management meets or exceeds company and industry standards and ensures that all services are in compliance with state and federal legal, regulatory, accreditation and reimbursement guidelines
Assists with the development of corrective actions, best practices, and/or education to appropriate employees
Conducts facility and/or region visits as needed to identify strengths and opportunities
Develops and provides information to identify trends, variances, practice patterns, and opportunities for improvement as part of the Division QAPI process
Recruits, hires, provides orientation/training, and retains a sufficient number of qualified staff to carry out the responsibilities of the care management function
Assists in the development of annual budgets
Develops and manages the implementation of strategies to provide effective and cost effective rehabilitation programs

Director of Care Management Resume Examples & Samples

Current or pending Connecticut Registered Nurse, Social Work, or Nurse Practitioner License required
Bachelors Degree and Master's Degree required
Certified Case Manager (CCM) or certification in care management related discipline
A minimum of five years recent experience in complex case management, long term stays, including nurse assisted case management, utilization management, and disease management; prior hospital/health care experience highly preferred
Experience with personnel management in including recruitment, job description development and disciplinary processes required
The ability to evaluate and perform data analyses using Microsoft Excel or equivalent is required
RAC Certification or RAC Certification eligible is preferred

Care Management Liaison Resume Examples & Samples

High school diploma or equivalent
Experience interacting with and engaging customers virtually over the phone
Minimum of two (2) year of customer Service experience in a healthcare environment
Professional experience in a healthcare setting and experience with referral/intake processing and pre-authorization processing is highly preferred. Specific experience with Oncology services/patient and chronic disease management, and lab referral processing is preferred

Complex Care Management Coordinator Resume Examples & Samples

One to two years of experience in a clinic, hospital or related health care industry in a managed care environment
Type 45-50 wpm
Computer skills and data entry experience
Ability to deal with confidential matters and the ability to work in a mutli-task, fast paced, deadline driven environment
Proficient in Microsoft Office programs (i.e, Word, Excel, and Outlook)

Care Management Resource Coordinator Resume Examples & Samples

3-5 years of administrative experience
Evidence of written and oral communication skills
Associate's degree
3-5 years of administrative experience healthcare industry

LPN for Care Management Resume Examples & Samples

Provides patient care, assessment, triage, and treatment
Provides input to Health Services Administrator, CenterPhysician, and Center Mental Health Consultant for case management ofstudent health issues
Executes student orientation to Health Services
Assists Health Services Administrator with center widestaff training requirements
Promotes and projects activities that support health andsafety throughout the center
(STD’s Diabetes, Weight Program)
Sicklecell, HBP, Asthma, Family Planning &Parenting Clinics
Provides for written standing orders on department andprocedures for health care
Performs quality assurance record audits
Participates in department system for student feedback andconcerns
Provides on call services and emergency care includingfirst aid and CPR; facilitates provision of emergency services on andoff center
Maintains accurate records for ordering, storage,administration, and disposal of medication/vaccines
Assists in monitoring use, maintenance, and disposal ofsupplies and equipment in Health Services

Senior Director, Care Management Resume Examples & Samples

Prior experience demonstrating leadership skills to achieve expected results and collaborating with groups across disciplines required
Minimum of 7 years clinical or healthcare-related experience should include experience in operational management and an understanding of healthcare finances
If RN, license to practice professional nursing in Pennsylvania and current BLS certification required
Clinical background (nursing, social work, therapy, etc.), and case management or related experience preferred as well as previous experience at CHOP and working across the organization in multiple departments
Experience with healthcare administration and business

MDS Care Management Coordinator Resume Examples & Samples

Ensures the initiation, completion and updating of the patient assessment instrument. Ensures that assessment information is accurately entered into the computer system and is transmitted within the time frames as mandatory regulatory requirements
Works with the health care team members to verify that both the medical record and the assessment instrument accurately reflect the patient’s status at the time of assessment, intensity of services provided and appropriate medical necessity for the services rendered to the patient
Ensures that correct Resource Utilization Group (RUG) classification is utilized for services needed and rendered to patient/residents and that the business office is informed of changes in RUG classifications
Coordinates schedule of patient/resident’s care planning conferences with the interdisciplinary team and invites family participation in the care planning process by issuing a written or verbal invitation to the conferences
Coordinates the development of the interdisciplinary individualized plan of care for all patients/residents according to the mandates of the Federal and State regulations
Serves as case manager for all Medicare and Managed Care patients/residents admitted to Medicare unit. Provides clinical services in the incumbent’s respective discipline, i.e. Staff RN, PT, OT, and SLP
Serves as an expert resource and educator to physicians and staff regarding the patient assessment instrument, third party reimbursement concepts and related processes. Stays abreast of and orients team on regulatory agency policies and computer system updates
Coordinates performance improvement and program evaluation activities for the unit. Conducts quality improvement and statistical data collection and analysis to evaluate the various aspects of program performance such as clinical performance, efficacy, patient outcomes, coding and billing as related to the services needed and rendered
Conducts in-services and continuing education of staff with emphasis on MDS, Care Planning, and Federal/State compliance
Participates in development of nursing policies and procedures with other members of the nursing leadership team

Director, Care Management Resume Examples & Samples

A Bachelor's Degree in Nursing
At least five to seven (5 - 7) years of progressive leadership in care management/utilization management programs with ability to develop and implement efficient and effective programs and operate at a senior administrative capacity within hospitals, physician groups and/or health plan
Recent professional experience with two (2)+ years working in a tertiary care hospital
Comprehensive knowledge of CMS Conditions of Participation related to utilization review and discharge and other federal and state regulations related to Care Management, Social Work, etc., across the care continuum
Knowledge regarding the healthcare market and government rules and regulations impacting health care reimbursement
Demonstrated results in planning, including analysis, statistics, budgeting and implementation
Demonstrated exceptional oral and written communication skills
Ability to work effectively with others as a team member, as well as gain cooperation and support through effective use of influence and persuasion
Strong leadership skills. Able to set clear expectations for others, implement and execute system-wide Care Management operations
Able to maintain an organized approach, clarity of purpose, and goal orientation in a rapidly changing environment involving multiple stakeholders throughout the organization
Results driven and able to drive quantifiable results throughout the organization. Proven skill set in solving complex problems, negotiating and developing actionable recommendations
Able to manage multiple priorities simultaneously and meet tight or conflicting deadlines
A Master’s Degree in related field
Knowledge of the UC San Diego Health organization is desirable
Executive level leadership over multiple sites and levels of care highly preferred
Professional experience in an academic health system setting
Working knowledge of Miliman Care Guidelines

Supervisor Regional Care Management Resume Examples & Samples

Sitting
Lifting up to 10 pounds
Push/Pull up to 50 pounds
Carry up to 10 pounds
Current unencumbered CA Registered Nurse (RN) license
Minimum three (3) years of experience in the acute patient care setting, including ICU or intermediate care units, Medical-Surgical Nursing, and/or Home Health
Minimum of two (2) years Medical Management experience, preferably in a managed care setting
Effective interpersonal skills: strong verbal, written and presentation skills
Ability to work well with staff for various educational and professional skills backgrounds to achieve common goals
Be willing to act. Is not immobilized by fear of failure
Accepts accountability for performance and decisions
Thorough computer knowledge, including on-line database and personal computer skills
Knowledge of wide variety of local and national resources for use in Care Management process
Utilization, Case Management, or Quality Management certification

Assoc Care Management Coord Resume Examples & Samples

Route Cases Based on Established Guidelines
Maintain or exceed department call center standards
Adhere to line of business phone standards to assure regulatory requirements are met
Utilize daily phone standard reports to assess opportunities for self improvement
Meet or exceed standards for other production and quality measures
Experience in customer service
Work experience with ICD-9 and/or CPT coding

Associate Care Management Coordinator Resume Examples & Samples

Proactively inform designated individuals of the status of work assignment to assure decision timeframes and notification requirements are met
Communicate effectively with Utilization Management Staff, providers, other internal and external customers and management
Provide accurate and timely routing of service requests to the nurse reviewer to assure that the decision and notification timeframes are in compliance with regulatory guidelines
Process service requests meeting established guidelines, and document and route requests that are not permitted
Request additional information verbally and in writing when the information provided is not adequate to make a medical necessity determination
Utilize phone functions to monitor the number of calls in queue and wait time
Experience in typing, keyboard and computer skills
Work experience in medical terminology
Associates degree or certification in a health related occupation

Manager, Enhanced Complex Care Management Resume Examples & Samples

Performs management responsibilities to include, but are not limited to: involved in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity
Plans, organizes, staffs, directs and controls the day-to-day operations of the department; develops and implements policies and programs as necessary; may have budgetary responsibility and authority
In collaboration with the Director, assists with focusing activities toward a strategic direction as well as develop tactical plans, drive performance, and achieve targets
Ensures that team members are clinically competent and adequately trained in motivational interviewing and other engagement techniques in order to achieve the market’s engagement and clinical targets for assigned population. Ensures on-going staff development through education and opportunities for professional development
Reviews department performance in relation to established metrics and implements changes in collaboration with other multidisciplinary team managers to effect continual improvement in the services provided
Leads/participates in both departmental and interdepartmental workgroups to continually enhance the delivery of programs and services and proactively respond to changing client and market expectations
In collaboration with the Director, participates in preparation of department budget. Makes budgetary recommendations and projections. Monitor, verify, and reconcile expenditures of budgeted funds. Identify cost savings opportunities within the department and/or operations
Ensures that all services are delivered consistent with applicable internal policies and procedures as well as applicable CMS, state, local, and regulatory agency requirements and applicable standards of practice for case management
Other duties as assigned or requested

Care Management Assistant Resume Examples & Samples

Functions as a key point of contact amongst Care Management, Utilization Review and Social Work staff, and payer source to obtain and document authorization for current and post-hospital care needs through the use of Health Connect patient information and approved guidelines
Prepares placement packets while in close communication with Physician, Transition Pharmacy, Staff Nurse, and others as applicable
Obtains and submits medical records for outside entities
Documents in progress note, such as tasks performed in the Skilled Nursing Facility (SNF) Transport, screening, etc
Coordinates durable medical equipment, such as ordering equipment and documenting in progress notes
Coordinates with Transition Pharmacy per policy; picks up medications to discharge patient
As directed based on patient needs, holds advance directive conversations
Schedules follow up appointments as needed
Provide secondary support to Patient Access Representative and Care Coordinators in providing important message from Medicare notices
Facilitates, identifies and documents all referrals and transportation arrangements to appropriate facilities or agencies; communicates status with case management and nursing staff; and completes transport packet
Collects and collates data related to patient care in collaboration with Care Management, Utilization review and Social work departments. Utilizes data for compilation related to, but not limited to, readmission, dashboards, etc
Interfaces with patients to communicate Medicare rights and to provide written documentation for the appeal process
Provides additional office support as required and based on operational need
Coordinates outpatient transitions and outpatient services, including, but not limited to, Mobile Health Partners, SNF, Project Access Now, Transport, Performs preliminary discharge screenings as directed
Other duties as assigned within scope of job description
Minimum two (2) years of experience related to clinical health care
AA/AS (two-year college degree) preferred
Basic knowledge/understanding of external regulatory requirements
Familiarity with managed health care environment
Familiar with healthcare organizations: structure and operations
Demonstrated excellent verbal and written communication skills
High attention to detail, critical thinking, good judgment in decision-making
Demonstrated proficiency with computers, email systems, and business office products including: Microsoft Word, Excel, PowerPoint, working in tables and document formatting

Manager of Care Management Department Resume Examples & Samples

At least of 5 years of experience in Care/Case Management (pediatric orthopedics and/or rehabilitation preferred)
Management or progressive leadership experience is required
BSN is required, Master’s in Nursing or other Health Care Related Field is preferred
Must have current unencumbered Oregon RN license
Must have CPR and PALS or PEARS Certification
Current Case Management Certification is preferred. If candidate is not currently certified in case management, certification by CCM or ACM will be required within 6 months of hire
Must have strong business computer skills and electronic medical record experience (Cerner preferred)
Bilingual and/or experience working with diverse cultures preferred

Manager of Care Management Resume Examples & Samples

Bachelor’s degree in clinical area or equivalent work experience
Current/minimum of 1 year of case management experience in an Inpatient Acute Care hospital setting
Minimum of 2 years of supervisory or leadership work experience
Must currently reside in or be willing to relocate to the Bakersfield, CA
2 years of experience in discharge planning from a hospital
2 years of utilization review/case management experience or social work experience

Supervisor, Care Management Resume Examples & Samples

Registered Nurse (RN) license issued by the state of California
Bachelor of Science in Nursing or Master of Social Work
Three to five (3-5) years of recent experience in the acute hospital setting
Two (2) or more years in social work, case management, utilization management or discharge planning
Skilled in negotiation, conflict management, employee relations, and team building
Expert communicator
MSN or LCSW
Accredited Case Manager or Certified Case Manager. (ACM or CCM)
Clinical Nurse Specialist (CNS)
Certified Professional in Healthcare Management (CPHM)

Care Management Growth & New Logo Sales Executive Resume Examples & Samples

Working in a multi-state regional territory, representing the Government Healthcare portfolio of products and offerings to both state and local agencies to address their claims management, Provider relations, Fiscal Agent, and transactional processing needs
Growing relationships with Conduent's largest Client(s) through cross selling of new services and capturing new client logos, using consultative selling expertise
Partnering with solutions leaders to develop product roadmaps to enhance focus service offerings in digital processing, payments, compliance and next generation customer care
Develop and support implementation of product roadmaps for focus areas and ensure alignment with Conduent and GHS business unit strategy
Partnering with Account Leaders and Base Sales executives to promote sales of new services into existing accounts
Recommending and initiating enhancements to the sales and marketing operations. Establish sales goals, analyze growth and provide accurate, complete and timely submission of required progress reports, forecasts, quotations, budgets and rates
Developing a detailed knowledge of Conduent services, solutions and offerings certainly within Government Healthcare, but also a basic understanding of Conduent's specialty BPO solutions (e.g., Call center, Transaction Processing, Learning, and F&A) and will help guide the client in major application and business decisions
Supporting the development of marketing plans that will appeal to a variety of customers on a global basis in order to support sales and profit objective
Representing the organization with executives and clients establishes and maintains effective relationships with internal and external constituents including consultants

Care Management Resource Center Specialist Resume Examples & Samples

Schedule primary care and specialty appointments for patients discharging from the hospital, with special focus on high risk patients
Initiate contact with post-acute agencies, provide updates as requested, facilitate placement, schedule transportation as requested and communicate discharge information to the TCC/SW
Provide necessary verbal and electronic communication to and from care management staff, serving as a liaison between hospital personnel and the various agencies
Serve as a central hub communicator for discharge plan information
Completes data tracking and collection to assist with the identification of routine statistics and problems or trends, such as turnaround time and issues with physician offices
Three to five years of current administrative/clerical experience working in Healthcare/and or related field

Care Management Assistant Resume Examples & Samples

Ability to handle sensitive and confidential information according to internal policies required
Knowledge and ability to articulate explanations of Medicare/HIPAA/commercial payor rules and regulations and comply with updates on insurance Utilization Review requirements preferred
Ability to work with technology as necessary to complete job effectively, including but not limited to
Proficiency in the software that is used on the campus where the employee is based
Phone technology (required)
Insurance verification/eligibility tools (required and training provided upon hire)
Scanning technology (required)
Fax Server (required if applicable to site and training provided upon hire)

Care Coordinator Complex Care Management Resume Examples & Samples

ENGAGEMENT: Interacts with patient and family caregivers, as appropriate, to ensure continuity of care, patient adherence to care plan, and identification of barriers preventing adherence to care plan/ intervention
EDUCATION: Coaches patients and family caregivers on how to use existing skills and develop new ones to make lifestyle behavior changes that can positively affect patient's health using different behavioral change modalities. Provides health education related to symptom management and preventative care in collaboration with the care team
ADVOCACY: Identifies and addresses system issues that impact barriers to patient’s care. Explores and explains all options available to address the patient’s needs. Encourages self-advocacy by educating patient and family caregiver on how to effectively navigate the healthcare system. Confirms patient and family caregiver’s understanding of needs and options
COMMUNITY LINKAGES: Coordinates care with other members of the care team to overcome any identified financial, legal or social barriers that inhibit patients’ medical care. Refers patients to health system and community resources to ensure patients have appropriate resources to overcome barriers to care (e.g. transportation, home care, durable medical equipment, pharmacy, housing, legal). Researches additional resources to expand knowledge base and make appropriate referrals
ALIGNMENT WITH ORGANIZATIONAL GOALS OF IMPROVING HEALTH OUTCOMES: Monitors the patients' goals and improvements in health outcomes with the care team. Focuses on preventive care and aims to reduce unnecessary medical utilization and as a result improves quality of care. Assists care team to close care gaps for individual patients on their panel,communicating these gaps with care team, and collaborating on a plan. Reviews standardized reports (e.g. quality, utilization, and productivity) and takes action as appropriate
DOCUMENTATION: Documents all patient encounters in relevant documentation system in accurate and timely manner

Clinical Case Coordinator Pshmg Care Management Resume Examples & Samples

Identify and enroll up to 150 patients into a chronic disease management and support program
Provide Chronic Case Management services to 150 identified Medicare participants
Works with area churches and community centers to disseminate evidence-based wellness programs and encourage patients to participate. These may include programs for strength training, social play, walking and cooking. The LPN will train community volunteers to run the wellness programs. The LPN will visit each program regularly month to monitor progress and provide supervision and support
Provides information and education regarding screenings, test results, and disease management
Serves as the system navigator and point of contact for patient and family, allowing patient and family direct access for asking questions and raising concerns
Performs duties related to transitional care management such as obtaining transition of care reports and completion of follow-up care as needed
Provides support for improving health behaviors and self-management skills: goal setting, action planning, and problem solving
Serves as catalyst to mobilize resources; assists in designing and evaluating systems that respond to patient, family and provider needs
Participates in data collection that includes patient care outcomes and will be responsible for Quarterly reports to the Medical Group. These data points are then used to continually refine/improve quality of care, identify inappropriate resource utilization, and promote patient and staff satisfaction
Uses computer-based tools to ensure data quality and integrity. Displays information in most effective format using graphics, spreadsheet or other programs
Adheres to Medical Group and departmental policies and practices regarding confidentiality and patients’ rights. Performs other duties as assigned
3 years experience in nursing required

100

Outpatient Care Management Resume Examples & Samples

Anticipates the needs and coordinates the comprehensive care of the Donegan patient population by maximizing resources to improve quality of care
Provides comprehensive case management services to identified clients of Donegan Family Center, with focus on reducing Emergency Room (ER) utilization and appropriate management of chronic disease conditions
Assists Patient Care Manager in implementation of Patient Centered Medical Home model and population health principles to improve health status of assigned patients
Other duties may include performing assessment, individual, family and group sessions; crisis intervention as necessary
Performs intakes, assessments, evaluations and referrals of assigned clients. Obtain sufficient information during the intake and evaluation process for diagnostic assessment and planning. Presents treatment and service plan to clients following the intake session. Provide the care needed as described in department policies and procedures
Performs appropriate treatment services to assigned clients. Use interventions with assigned clients, which meet accepted and current standards of care and reflect consideration of the treatment plan. May provide crisis management for assigned cases and is able to provide back up for the program. Maintain amount of weekly scheduled client hours as required by departmental needs and standards
Provides services to adults, adolescents, children, couples and families, using knowledge and skills necessary to provide care appropriate to the age of the patient
Maintains a dialogue with the behavioral health specialists and other Center providers to facilitate a team approach in treating patients
Participates as a treatment-team member. Attend clinical supervision meetings and staff meetings as scheduled and come to meetings prepared. Keep current with professional literature and trends. Attend at least one professional conference or seminar annually
Maintains active communication with identified staff and agencies that share case involvement when appropriate releases are signed
Maintains appropriate records of services rendered to, or on behalf of, the client populations served. Maintain clinical records of all client contacts according to QA & I, State and JCAHO guidelines. Produce an evaluation report which effectively addresses the reason for referral and reflects the sound organization and synthesis of fact, impressions and clinical recommendations. Complete progress notes, reports and correspondence in a timely manner
Exercises appropriate self-management in the performance of all duties
Completes client satisfaction tools as required by departmental standards
Performs thorough Risk Assessment at intake session and as needed thereafter. Comply with Network and departmental policies regarding issues of employee, patient and environmental safety and follows appropriate reporting requirements

101

Care Management Clinical Associate Senior Resume Examples & Samples

Completes review of clinical history for selected members, summarizes data, and refers members to IHM programs as appropriate
Applies focused clinical experience, benefits and claims payment knowledge to pre- and post-service reviews
Leverages clinical knowledge, business rules, regulatory guidelines, and policy and procedures to determine clinical appropriateness
Responsible for timely collection and comparison of the individual’s health status to normal finding or criteria with concise documentation of pertinent facts and rationale in the electronic record
Responsible for following peer review process, mandatory medical director, informing leadership of sensitive or complex cases
Completes case documentation according to regulatory standards and clinical procedures
Maintains confidentiality of member and case information by following corporate and divisional privacy policies
Monitors and develops reports to ensure departmental compliance and reporting needs are met
Accepts responsibility for independently completing special projects or reports as assigned
Serves as a department resource
Maintains outstanding level of service at all points of member and provider contact
Collaborates and coordinates with team members to facilitate day to day functions and enhance the overall operation of the department
Serves as a subject matter expert to team members and mentors as necessary

102

Care Management Assistant Resume Examples & Samples

Assists in data gathering, ie; admission and discharge dates and disposition as directed by the Utilization Management staff
Assists in data entry as requested by UM nurses
Enters authorizations for payment of service into the documentation system
Coordinates data with the case management team and provider, when indicated by the UM Nurse
Utilization Management Assistants/SSC must remain objective in their review and not participate in any way in the delivery of care to the patient and
Healthcare related experience is preferred

103

Supervisor Care Management Resume Examples & Samples

Supervise the team and acts as a resource for care management professional and support staff
Oversee and coordinate team activities to achieve business objectives and ensure medically necessary, cost-effective, quality care is delivered to members through various care management programs, including case management, disease management and care coordination
Demonstrated competency in setting priorities for a team and overseeing work outputs and timelines
Ability to communicate effectively, verbally and in writing including with employer or provider groups
Ability to effectively develop and lead a team (including employees who may be in multiple locations or work remotely)
Demonstrated experience in recognizing problems and effectively resolving complex issues
Familiarity with health insurance industry trends and technology
Demonstrated competency related to clinical case management and utilization management practices
Experience using population statistics and their application in care management programs
Must have licensure or certification, in a state or territory of the United States, in the health or human services-related field that allows the professional to conduct an assessment as permitted within the scope of practice of the discipline (e.g. medical vs. behavioral health) and at least 3 years full time equivalent direct clinical care
For medical care management, must have a current unrestricted Registered Nurse (RN) license, in a state or territory of the United States
Certification as a case manager from the URAC-approved list of certifications preferred

104

Supervisor, Reg Care Management, LVN Resume Examples & Samples

Provides direct supervision, guidance and professional development to Regional Care Management staff including hiring, job training, communication and disciplinary counseling as needed
Supervises and works with Care Management staff by assigning, communicating and delegating department responsibilities such as reports and audits
Supervises workflow of the Care Management department
Provides oversight for contracting and benefit eligibility issues (senior and commercial) as requested, and ensures that staff verifies eligibility, benefits, and co-pays on all requests
Clarifies eligibility, benefits and co-pays with health plans as needed
Triages referral within appropriate time frames. Develops processes for review of all incoming referrals
Reviews prior authorization requests for content, thoroughness and completeness and confirms coding for accuracy
Monitors progress of pending requests, verifies accuracy of reports, and investigates incomplete requests according to Care Management policies and procedures
Ensures utilization management compliance with CMS/DMHC/NCQA requirement standards, collects and analyzes data to identify over/under-utilization and referral patterns
Reports utilization management outcome measurements to Care Management Committee (CMC) on a periodic basis to identify and review standard of care delivered
Ensures appropriate levels of care and utilization of medical facilities and services within the parameters of the patient’s benefits and/or CMC decisions
Identifies quality of care issues and works with Manager/Director/VP, Regional Care Management and Quality Improvement department to resolve quality of care issues
Communicates authorization and/or denial of services to appropriate parties in accordance with Care Management policies and procedures
Coordinates provisions for ambulatory care be referring patients to the appropriate source (i.e., home health, social services, behavioral health, health education, community resources, etc.) in order to maintain continuity of care
Participates in the development of Care Management processes with other regions to ensure uniformity across the organization
Ensures compliance with medical group policies and procedures as well as regulatory standards
Analyzes work processes and identifies areas where policies, procedures and quality could be improved
Participates in the orientation and training of new employees
Manages departmental budget/cost containment
Communicates with and refers to Manager/Director/VP, Regional Care Management all cases involving appeals, grievances, quality improvement and risk management issues. Collaborates with manager to solve complicated requests
Working knowledge of Microsoft applications (Word, Excel, Access)
Working knowledge of CMS, NCQA, DMHC, HEDIS, medical and regulatory agency guidelines
Excellent verbal and written communication skills. Ability to effectively communicate and collaborate with physicians, patient/families and ancillary staff

105

Director, Care Management Operations Resume Examples & Samples

Responsible for the development and execution of care management activities to drive compliance with health plan partners’ models of care
Develops and maintains collaborative relationships with other internal market leaders, payor partners, regulators and corporate teams
Leads cross-functional clinical and non-clinical meetings and other projects
Functions as market care management leader during implementation as needed to accommodate organic and new product growth
Monitors care management clinical operations as well as contractual and regulatory operational requirements during implementation and post-implementation to drive compliance, quality outcomes and operational efficiencies
Functions as care management subject matter expert, understands and maintains knowledge of delegated lines of business and community provider relationships
Monitors staffing and budget for care management
Supports and oversees care management acuity assignment methodology, including supporting new technology development by defining business specifications/requirements for clinical operations
Oversees risk stratification guidelines compliance through reviews of care management activities and systems reporting
Identifies and executes on best practices for care plan development and management
Responsible to support achievement of cost, quality and patient/member experience goals
Leads the care management and social work teams ensuring they are effectively and efficiently operated, resourced and performance managed by market leadership
Directs, plans and evaluates care management documentation quality through independent reviews and through the monitoring of the internal quality review tool(s)
Develops care management policies, procedures or other job aides as needed
Participates in collaborative meetings between care center staff/providers and care management across all markets, leads clinical operations oversight meetings and maintains agenda and written meeting minutes
Develops performance improvement plans or other quality monitoring tools to support performance expectations for all staff
Tracks and reports to supervisors and other market or corporate leadership using systems reports on a defined frequency, taking efforts to validate accuracy and completeness on a regular basis
Participates in personnel management including recruiting, hiring, goal setting, evaluations and team building
Promotes a positive work environment, sets an atmosphere of open communication and feedback
Performs, at a minimum, an annual assessment of operational performance across all key success metrics
3-5 years Health Plan care management experience required. Experience with MMP and/or DSNP programs required. Healthcare provider experience preferred. Ability to travel 15%, mostly within the state. Ability to work in a Windows based computing environment. Strong interpersonal and critical-thinking skills
Education/Experience: RN required, Bachelor’s degree required, Advanced degree preferred
Language Ability: Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals
Ability to write routine reports and correspondence. Ability to speak effectively before groups of customers or employees of organization
Math Ability: Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent and to draw and interpret bar graphs
Reasoning Ability: Ability to apply common sense understanding to carry out instructions furnished in written, oral or diagram form. Ability to deal with problems involving several concrete variables in standardized situations
Computer Skills: Must be able to proficiently use Microsoft Office skills and clinical applications

106

Senior Medical Director of Care Management Resume Examples & Samples

The Senior Medical Director for Care Management will be the organizational champion for coordinated care for all patients
Have overall responsibility for ensuring that HealthEast’s care management, population management, and transitions of care management activities are effectively operated, resourced, led, and monitored
The Senior Medical Director will participate in HealthEast’s Accountable Care Organization leadership meetings and will partner with HealthEast’s Chief Medical Information Officer and the Information Services team on health information initiatives that directly impact care coordination
The position will also coordinate with the Chief Financial Officer and the Finance team to analyze and determine ROIs where pertinent for various care management programs within the ACO or other value based care initiatives
Specific responsibilities include the following: Lead Care Management program development and deployment in primary care with dyad partner: Establish and support efforts to design, develop, adopt, and implement care and disease management pathways, standardized practices and performance standards, and clinical and operational protocols for populations of interest/ intervention
Develop clinical programs that align directly with “triple aim” goal of improving healthcare which includes, but is not limited to: Identification of key program elements
Input on design and structure of programs working closely with Primary Care Leadership Group to ensure successful execution of programs
Monitor progress/outcomes, and provide suggestions for modification of programs as needed
Cultivate and maintain a current understanding of leading practices to improve the quality and effectiveness of care management delivery across the continuum of care, and consistently work with leadership to deploy effectively throughout HealthEast. Proactively identify and alert leadership of any potential issues related to quality and clinical programs, and make actionable recommendations for avoiding identified issues
Maintain a clinical practice
Ensure optimal transitions in care for patients across the continuum of care: Ensure effective transitions between acute care and ambulatory primary/specialty care practices
Lead and provide technical expertise for the design, development, acceptance, and implementation of HealthEast’s transfer protocols, ensuring that they properly identify candidates for care transition and coordinate closely with broader care management pathways
Actively monitor the safety, effectiveness, and efficiency of “hand-offs” in care across the continuum of inpatient and outpatient management of HealthEast’s patient population
Optimize efficient patient care- related communications between and among hospital- based practitioners as well as with pre/post hospital providers of care
Build and maintain an effective post-acute and senior care network: Identify preferred providers, develop a credentialed post-acute network, and specify affiliation criteria in terms of operational flow and quality outcomes
Ensure effective transitions between acute care and ambulatory primary/specialty care practices
Be primarily accountable for the quality, effectiveness, efficiency, coordination, and satisfaction related to HealthEast’s care management relationships with primary, community, and sub-acute care rendered to its patients
Support medical group and health system efforts to reduce unnecessary variation and inefficiency in clinical practice and communications within hospital based care
Establish accountability for Case Management, Care Management, Discharge Planning and Transitions of Care functions, and other related continuum-management functions
Ensure that the quality, effectiveness, and efficiency of hospital-based care is appropriately consistent across providers of care
Optimize efficient patient care-related communications between and among hospital- based practitioners as well as with pre/post hospital providers of care
Develop analytic and reporting infrastructure to support achievement of goals
Collaborate with clinical and administrative leadership to develop meaningful analytics and metrics for care management and appropriate IS interoperability, which supports the system’s care management goals
Collaborate in the development of a robust clinical. informatics/clinical decision support function that informs and monitors implementation of the care management activities
Design appropriate care management dashboards, reports, and alerts
Advocate for an accessible and compatible clinical information and informatics functionality to support optimal care management
Support maintenance of physician reporting capabilities which will allow for the measurement of key performance and quality outcomes by physicians, as well as provide a mechanism for providing feedback to member physicians
Responsible for developing and mentoring leaders within areas
Establishes performance standards, identification of goals and outcomes
Drives employee selection and ensures employees are orientated to the organization, business unit and position
Develops and manages financial forecasts for entity
Along with senior management team, accountable for closing gap between run rate and target
Plans, directs and oversees annual budget development and ongoing management for all areas of responsibility
Manages capital project budgets
HealthEast Leadership Competencies - Building Organizational Capability
Recognize that staff development is an essential building block for organizational success
Establish performance goals and objectives, monitor progress against agreed upon metrics, and provide accurate behavioral feedback in a manner that maintains self-esteem
HealthEast Leadership Competencies - Change Management
Inspires others to embrace change by displaying the proper attitude toward change while helping others to understand the need for and benefits of change
Engages key stakeholders in the communication and planning processes to ensure buy-in
Being flexible and adaptable in the face of organizational change
HealthEast Leadership Competencies - Emotional Intelligence
Demonstrates insight into the emotions and motivations that underlie human behavior and using those insights to build effective relationships with others
Expressing self-awareness, personal responsibility, and confidence
HealthEast Leadership Competencies - Execution Focus
Develops and implements systems designed to maximize personal, team, and organizational success
Achieves quantifiable and measureable results across a variety of tasks despite obstacles, risks, distractions, or pressure
HealthEast Leadership Competencies - Keeps an open mind, and seeks out new ideas and ways of doing things, particularly when faced with novel situations
Studies, analyzes, and understands new situations and new business problems and applies this new knowledge to other situations
HealthEast Leadership Competencies - Transformational Leadership
Creates and maintains high levels of energy, instilling pride, and sustaining a vision
Motivates and inspires the organization to achieve at the highest levels
Fosters an environment where staff is motivated to take on new challenges and provides sufficient support for their efforts
Physician Medical License from the MN Board of Medical Practice required
Board certfied in any of the following specialties: Family Medicine, Internal Medcine and/or Pediatrics
15 years of clinical experience, including substantial working familiarity with ambulatory/primary care and processes and a deep working understanding of the functions of a health care system
Demonstrated leadership experience that has included accountability for the design and effectiveness of care improvement, care processes, and/or transitions in care
Demonstrate a significant track record of administrative achievement in a setting requiring voluntary collaboration among diverse, independent-thinking constituencies
Display a working knowledge of contemporary medical informatics, clinical decision support systems, and electronic medical records
Demonstrated ability to serve as an effective and trusted liaison across organizational boundaries and between physicians and administration
Possess a good working understanding of hospital and practice finance, including an appreciation of how current global payment mechanisms, accountable care, “and other diverse reimbursement and incentive programs impact both physicians and hospital constituencies
Be comfortable and effective navigate a matrixed environment
Have a sound background and some formal education and/or training in the areas of health improvement, process improvement, population health, and/or health systems planning
Experienced in the design and implementation of large scale, local process, and quality improvement, including exposure to LEAN/Six Sigma, and other redesign and improvement methodologies

107

Market Medical Director Complex Care Management Resume Examples & Samples

Achieve sustainable, profitable growth via new business development and growth
Promote the clinical and financial value propositions to new business and current partner stakeholders to achieve growth goals
Engage and speak with state and local organizations, LTC industry associations, medical society memberships, etc. regarding value and quality outcomes of the models
Develop and sustain strong relationships with other medical directors and health care system leaders in market territory
Actively engage NP / PA clinical staff with didactic, written and 1:1 education on geriatric syndromes, chronic illness, SNF regulations, and end of life / palliative care
Develop and revise clinical practice standards and procedures
Leadership role for achievement of targets for market or contract specific STAR; HEDIS measures; and Quality Improvement Programs
Lead market review and develop education and operational plans to address pharmacy , acute hospitalization, skilled SNF services, DME, and physician medical expense
20-30% day travel within market with occasional travel to other markets
MD or DO in State of Florida
Health care management/leadership experience
CMS, Medicare Advantage, SNP Rules and Regulations
HCC and Risk Adjusted reimbursement methodology
State specific collaborative practice agreements and midlevel practitioner licensing

108

Care Management Coordinator, LVN Resume Examples & Samples

Coordinate with physician extenders, primary care physicians, and ACO Clinical Services Department to ensure high value health care
Facilitate the transition between care environments and provide appropriate care interventions
Develop transition plans that are patient-centered, promoting quality and efficiency, strategic relationships with health systems, hospitals and other inpatient facilities, physicians and physician groups, and Accountable Care Organization groups
Facilitate enrollment of members into one of our care management programs
Assist the patient with community-based support and activities
Conduct Health Risk Assessments (HRA) telephonically and/or in person as needed
Collaborate with team members to reduce adverse events and prevent functional decline
Develop streamlined, evidence based plan of transition
Obtain all other paperwork pertinent to care transitions and coordinates with Physician Extender and Patient Navigator
Assist patient in developing a personal health record and ensures it is updated and accurate upon discharge from home health and/or Care Management
Must be a graduate of an approved school of nursing and be a licensed vocational nurse (LVN) in the state in which he/she currently practices
Must have a minimum of 2-3 years' nursing experience
Must have a thorough understanding of the federal, state, and local laws and regulatory guidelines governing the operation of a home health and hospice agency
Previous Home Health experience

109

Coordinator, Complex Care Management Resume Examples & Samples

Ability to use 10-key calculator by touch
Computer skills including MS Excel
Excellent customer service and communication skills, handle heavy phones, be organized and self-starter
Knowledge of HMO/Medicare/Medi-Cal insurances

110

Supervisor, Harp Care Management Resume Examples & Samples

Fluency with the Recovery model, and the demonstrated ability to promote the Recovery Model throughout workflows
Skilled to manage a diverse staff; execute corporate function effectively; ability to communicate professionally and with cultural sensitivity
One to three years Supervisory experience working in a heavily regulated environment, supervising individuals who provide recovery oriented services to SMI/SUD populations & related service delivery
Three years clinical and/or managed care experience that involved assessment of treatment and service needs, and formulating integrated plans of care that impact desired recovery outcomes and quality of care. Experience with specialty populations (e.g. first-episode psychosis, justice involved, transition-aged youth)
Experience navigating the NY State systems of care, including Home & Community Based Services (HCBS)
Experience with providing and/or coordinating integrated, person-centered care
Experience with evidence based practices in behavioral health care
LCSW, LMHC, RN, or Licensed Psychologist (Ph.D. or Psy.D.) required; CASAC a plus when in conjunction with required clinical licensure
Master's degree required

111

Supervisor Operations Integrated Care Management Resume Examples & Samples

Bachelor’s Degree in Health Related Field
1-3 Years of Field Supervision
1-3 of Logistics/Scheduling
Lean Six Sigma Preferred
Metrics tracking experience preferred

112

Director of Care Management Resume Examples & Samples

Implements and monitors the case management program
Develops and maintains an integrated clinical care management model that fosters appropriate levels of care and maximized reimbursement
Oversees and monitors compliance and regulatory activities
Oversees compliance activities related to CMS, Joint Commission and state requirements in the hospital setting, including the maintenance of hospital/network standardized policies and procedures
Develops and maintains standardized initiatives related to hospital case management, including LOS, OBS, multidisciplinary rounding, effective discharge planning and hospital social work activities (general and specialized)
Two years of direct management (supervisory) experience required. Two years of Care Management experience preferred

113

Director Integrated Care Management, RN Resume Examples & Samples

Required Bachelor's Degree Nursing and CCM (Certified Care Manager preferred) or Licensed Social Worker
Required 3- 5 years Director level/people management experience
Required 5-10 years progressive Healthcare experience, Case Management experience and preferably within Managed Health Care
Required extensive and proven knowledge of EPDST and HEDIS measures; and NCQA requirements
Required proficiency with Microsoft Office Suite (Word, Excel, Power Point), Access is a plus. Consistent word processing speed and accuracy of 50 or more words per minute

114

Licensed Manager of Care Management Resume Examples & Samples

Minimum of 5-7 years in clinical area of expertise required
Master's degree and active unrestricted State Licensure in applicable functional area (RN, LPC, and/or LCSW) required
Background in Behavioral Health strongly preferred
Registered Nurse (RN)
Licensed Professional Counselor (LPC)

115

Supervisor Care Management Resume Examples & Samples

Supervises the team and acts as a resource for care management professional and support staff
Oversees and coordinates team activities to achieve business objectives and ensure medically necessary, cost-effective, quality care is delivered to members through various care management programs, including case management, disease management and care coordination
Palliative Care experience preferred
Must have a current unrestricted Registered Nurse (RN) license, in a state or territory of the United States and at least 3 years full time equivalent direct clinical care

116

Director, Integrated Care Management Resume Examples & Samples

Minimum 5 years of progressive healthcare experience
Minimum 3 years of management experience
Proficiency with Microsoft Office Suite (Word, Excel, Power Point). Access is a plus
Consistent word processing speed and accuracy of 50 or more words per minute

117

Care Management Manager Resume Examples & Samples

Critical thinking ability with assessment and summarization skills
Excellent verbal and written communication skills with patients, physicians, families, and other health care providers
Demonstrates flexibility and adaptability to changing health care environments
Basic knowledge of computers and clinical applications
Active RN licensure (has not been censured and/or forced to relinquish due to impropriety)
At least 2+ years of supervisory or leadership experience
At least 1+ year of case management work experience
Experience in hospital work environment clinical setting
Must live in or near Glendale, California area and/or willing to relocate
National certification in case management
At least 2+ years of utilization review/case management experience or social work experience
At least 2+ years of discharge planning experience in a hospital setting

118

Director Care Management Patient Logistics Resume Examples & Samples

Providing management direction to departmental leadership and staff
Developing and implementing strategic initiatives related to the smooth and orderly management of inbound/outbound transfer requests, hospital bed placement and contributing to the development and implementation of the hospital capacity management strategies
Being held accountable for Productivity, Human Resources Management, Internal/External Customer Service, Goals/Outcomes Management, Budget Management, Compliance and Quality/Process Improvement initiatives to ensure a high level of quality consistent with organizational standards
Reporting to the Director of Care Management

119

Coord, Care Management Resume Examples & Samples

Develops an individual plan of care for each patient reflecting goals, treatment plans and outcomes for each patient
Collects accurate and timely health care data and adequately documents patient related issues, provider related issues and appropriate use of codes (ICD-9, DRG, HCPCS and CPT codes)
Reviews claims and follows up on pending claims
Provides health coaching services to defined population, including education regarding disease processes, prevention, positive healthy behaviors, screenings, appropriate use of health care system, education regarding health plan and benefits
Assists in the development of care management programs and in the development of outcome monitoring systems and reports to measure the impact of the programs
Assists in the updating of electronic case management system to enhance the care provided in the care management programs and the development of additional Select products

120

Supervisor, Care Management Resume Examples & Samples

Assess staff member's ability to engage members and provide coaching to increase the use of motivational techniques. Complete performance evaluations within departmental timeframes
Collect data, validate data where possible, prepare reports and assist teams in analysis and monitoring of key utilization targets and trends
Conduct regularly scheduled team and individualized meetings to communicate information, ongoing education and/or individual performance feedback
Contribute to the development, implementation and annual review of departmental policies and procedures
Ensure staff receives, understand and adhere to applicable regulatory/ compliance guidelines related to their departmental expectations (I.E. NCQA, DPW, CMS)
Bachelors degree in nursing -OR- in another field required
4 years of experience related to geriatric nurse or care management required
Previous geriatric/skilled nursing experience a plus
Previous supervisory or leadership experience preferred, but not required
Case management certification or approved clinical certification within one year of hire
Ability to collaborate effectively with physicians and other health care professionals
Strong organizational and problem solving skills with ability to make decisions independently
Ability to develop and maintain effective team-focused working environment

121

Director, Inpatient System Care Management Resume Examples & Samples

Patient Care Coordination activities including system-wide Case Management, Care Coordination and Discharge Planning, developing and implementing Care Management Metrics, Case Management policies, practices and procedures and integrates managed care contract criteria into overall Case Management functions
Provides AHS physicians, nursing and staff education
Serves as Content Expert/Liaison
Support the VP of CM with completion of financial analyses
Oversee Nurses, Social Workers, and Administration Staff
Oversee patient, physician and staff satisfaction based on quality outcomes and patient experience reporting, and identify utilization issues affecting the quality of patient care
Work closely with the VP of Care Management and Physician Advisors on any audits and secondary reviews
Oversee educational needs and plan for inpatient Care Management division
Recruit, train and coach management staff

122

Care Management Program Coordinator Resume Examples & Samples

Serves as a Liaison with AHS and community service providers, volunteers, community organizations to enhance service delivery and collaborative efforts on behalf of the program and the AHS patient population
Assists with the oversight of projects and initiatives for the department; communicates project status to team and business owners throughout the duration of the assignment and post implementation
Develops and maintains service delivery program(s)/projects under CM Leadership; assists with day-to-day operation of the program including scheduling, delivery and evaluation of program services
Support programmatic activities including but not limited to leading program meetings, developing correspondences and presentations, compiling and maintaining accurate records and files, supporting program staff schedules and developing or updating program narratives or vignettes
Documents and reports Care Management programs activities in AHS systems
Recommends and facilitates implementation of procedural and operational changes to maximize service delivery, consumer satisfaction and potential funding opportunities
Organize and develop training for program staff and/or volunteers including recruitment and retention efforts
Supports on boarding processes for all new staff or volunteers
Assists with any program marketing collateral materials in various approaches (e.g. intranet, internet, social media and publications)
Designs, develops and implements work flow procedures and policies, and revises procedures and manuals, ensures the availability of current information by collaborating with CM leadership Team
Provides consultation and technical assistance to internal or external partners (e.g. health care providers or other entities) to define or modify industry standards and best practices

123

Care Management Clinical Appeals Specialist Resume Examples & Samples

Initiates the appeal process, at the direction of the Supervisor and/or physician advisors, until the case is overturned, appeal options are exhausted or decision is made to discontinue process; assumes the responsibility for coordinating and appealing clinical denials per department policy; develops any appeal letters to substantiate the medical necessity for admission or continued stay using evidence from the medical record and clinical review tools, as well as input from the attending physician and/or Physician Advisor, complies with all submission time frames and other guidelines outlined by the third party payers and auditors
Tracks and trends progress and outcomes of denial and appeal processes and compiles reports for division and AHS leadership Assures clinical interventions are appropriate for the admitting diagnosis and reflect the standard of care, as defined by the medical staff and the organization; utilizes clinical knowledge and defined standards of care to proactively identify inappropriate admit status based on identified criteria and ensures the patient is registered at the appropriate level of care; Utilizes McKesson Interqual® clinical guidelines; refers questionable cases to the CM Manager or physician advisor for determination
Communicates with physicians and multidisciplinary health team members to maintain the multidisciplinary team approach to ensure effective resource utilization and appropriate level of care
Coordinates all utilization review functions, including response to payor requests for retrospective review information including Medicare and MediCal regulations/requirements; ensures the appropriate level of care is assigned and documented on all patient medical records
Coordinates with Care Management team when cases do not meet criteria; coordinates denials with the attending physician and the Care Management physician advisor; prepares case reports; documents treatment plan, progress notes and discharge summary related information as required by Medicare, MediCal, Title 22 and other mandated regulations according to Department standards
Develops, collects, trends and analyzes data relevant to the utilization of healthcare resources including but not limited to avoidable/variance days, readmissions, one-day stays, DRGs, LOS

124

Mgr, Care Management Resume Examples & Samples

5 years’ experience in health care with emphasis in case management
2 years in a leadership or management position
One year experience with MediCare SNF/Rehab guidelines

125

Director, Care Management Resume Examples & Samples

Direct all care management and social service functions within the hospital and the transition of care. Responsible for establishing and maintaining systems and processes that optimally provide for effective and efficient delivery of patient care. Work closely with leadership in establishing and maintaining systems that optimize outcomes for all entities involved. This includes prospective, concurrent and retrospective utilization management, discharge planning and social work functions. Assure inter-rater consistency and staff competencies
Integrate and coordinate all related services of Care Management within the hospital with the associated Physician Networks. Develop integrated plans that effectively transition patients throughout the continuum
Direct the processes necessary for data collection and the management of pertinent integrated information. Participate in the review, interpretation and decision-making regarding resource management. Monitor and track variant and avoidable bed day visits and other utilization trends. Report data as required to appropriate entities. Implement corrective actions as deemed appropriate
Create a collaborative team both within the ministry as well as across the continuum with all departments which impact care management, social services and utilization management outcomes. This includes coordination and communication with Medical Staff, Nursing, Quality, Revenue Cycle Services, Health Information Management, Contracting, the ambulatory setting and other functional areas that impact the flow of patient care and the utilization of resources
Develop and manage operational and capital budgets, including ensuring staffing schedules are consistent with targeted productivity
Maintain comprehensive knowledge of payor and regulatory requirements assuring that all functions meet internal, Health Plan and regulatory body requirements

126

Director, Care Management Resume Examples & Samples

Required; Master's degree preferred
Eight to ten years in a managed care environment
Ten years of clinical experience required, preferably in a pediatric environment
Track record of strong clinical utilization and care program management, general management, supervisory team building and leadership skills
Experience in LTSS program management
Excellent time management and prioritization skills to focus on multiple projects simultaneously and adapt to change
Strong personal computer skills, including working knowledge of Microsoft Office suite

127

Director of Care Management Resume Examples & Samples

Previous experience in care delivery in a managed care environment
Correctional environment preferred
Previous experience working with utilization management
Computer data entry needed
Provide direction of day to day functions of the Care Management Department
Provide clinical perspective and best practices support to RCM staff through one-on-one coaching, team facilitation, and training
Work to improve the utilization management process, including considerations of efficiency, effectiveness, and accuracy
Develop and implement RCM care management processes in collaboration with the Vice President of Care Management to support corporate UM initiatives
Promote and maintain positive relations with all stakeholders
Provide clinical and operational oversight of each medical management initiative including utilization management. Analyze clinical data to drive each initiative
Review and revise Care Management and Utilization Management program descriptions annually or as indicated by contract or accreditation requirements
Responsible for training RCM staff including new employee orientation and skill development
Identify opportunities to improve clinical care, customer service, and internal business processes
Collect, report, trend, and analyze Care Management program elements for departmental productivity and performance outcome reporting
Assist Vice President of Care Management in planning and conducting Care Management Committee functions
Develop, manage, and participate in intra- and inter-departmental projects, workflow processes, policies and procedures in collaboration with internal and external stakeholders
Responsible for staff performance evaluation and management

128

Supervisor Integrated Care Management, RN Resume Examples & Samples

Required Bachelor’s Degree. Master’s Degree preferred
Required Registered Nurse or Licensed Social Worker
Required unrestricted license to practice nursing/social work in the Washington, DC
Required 1-3 years' field supervision
Required 3-5 years' case management experience
Preferred certified as a Case Manager

129

Care Management Strategist Resume Examples & Samples

Acts as the subject matter expert for clinical operations and regulatory reporting requirements for risk based contracting, Medicare and Medicaid billing practices and overall care coordination strategies in population health
Understand and can articulate care coordination workflow processes and procedures across service lines, care settings and healthcare providers
Defines scope of services and technology to expand new business models into future markets including direct to employer, grant management, business partnerships, and payer models
Assists in directing the implementation of Care Management strategies for complex care coordination, disease management, utilization management, pharmacy management, wellness, Primary Care Medical Home Initiatives and other medical management strategies designed to enhance health outcomes and reduce the cost of care for the Medicare and Medicaid populations
Articulates the current competitive landscape and conducts market research to stay current with changing regulatory reporting requirements. Redefines existing scope of services and technology to meet competitive landscape and regulatory and accreditation agency guidelines
Collaborates across solution groups on similar functionality to ensure common process and seamless integration; protects innovation through the patent process and supports Cerner sales and Marketing processes
Ability to build and maintain strong partnerships with external organizations
Ability to influence work in a highly matrix, entrepreneurial environment
Demonstrate ability to deliver results through leadership
Working knowledge of CMS and Joint Commission, state and federal regulations affecting population utilization, and case management; third party reimbursement including fee-for-service and capitation for commercial, Medicare
Bachelor’s degree in nursing or related field is required
RN license required for State of Practice
At least five years of progressively responsible management experience and experience in Population Health, Care Management, Utilization Management and Managed Care or comparable combination of experience
Ability to travel 40-60%
Live or willing to relocate to Kansas City
Master's degree in Nursing, Health related field, or Public/Business Administration or equivalent combination of education and experience

130

Director, Care Management Infrastructure Resume Examples & Samples

Responsible for the design, implementation and optimization of telephony, web, email, IM, mobile, video capabilities critical to inbound, outbound, synchronous and asynchronous CRM requirements and tie-in with HealtheCare functionality/usability
Design/configuration of interfaces/points of integration of analytic output of risk-stratification/identification, case-load prioritization and business rules maintenance that drive work-load routing, queueing and related automation capabilities
Design/configuration of data capture of all back-end activities/interaction for tracking/reporting of care management service delivery performance
QA call recording/sampling and other technical aspects as defined by the operations to ensure appropriate call/interaction history capture, audit and reporting requirements
Direct management experience of a large-scale storage operation, enterprise level networking (including MPLS, routing, and switching), as well as server hardware and software (Microsoft Windows, SQL Server, Clusters, Active Directory, SCCM, Xsigo, and VMWare ESX)
Ability to work independently, and within the framework of enterprise technology process and budget guidelines and translate corporate strategy into objectives for managed departments
Ability to define and manage objectives for departments and individual team members
Excellent oral and written communication skills to interact with all levels in the organization including senior management
Ability to engage 24/7 for escalation management
Ability to manage multiple projects and deadlines effectively
Travel 10-20%
Reside in or be willing to relocate to Kansas City
B.S. Degree in Computing Science, Technology Management, Engineering or similar or relevant experience
5+ years of progressive infrastructure technology management experience
Working knowledge of ISO 27000 series standards
Experience with design and operations of CRM organizations

131

Regional Director, Care Management Resume Examples & Samples

Coordinates implementation of an effective corporate care management program
Evaluates pertinent care management metrics throughout the LifePoint system, identifies priorities for improvement, and recommends actions to address priorities
Conducts onsite assessments of case management programs; works with onsite hospital teams to develop effective corrective action plans; monitors results of improvement actions
Maintains open communication with corporate division leadership regarding performance of individual hospitals within the specific division
Establishes and implements an education plan for orienting and developing LifePoint case management professionals
Provides targeted education, assistance, and consultative support to LifePoint hospitals
Manages the corporate CM toolkit to keep it current, compliant with CMS requirements, and of maximum benefit to hospitals
Serves on assigned corporate committees and workgroups

132

Integrated Care Management AVP Resume Examples & Samples

Accountable for developing a measurement and evaluation plan for all Integrated Care Management goals and developing programs that ensure high-quality clinical outcomes for patients of care management programs
Directs the development, implementation and monitoring of Integrated Care Management initiatives through collaboration with operations and clinical leadership teams
Develops and directs programs that strive for optimal allocation of resources so that patients receive the right service at the right time from the right provider in the right setting
Is responsible for the achievement of total cost of care targets for patients receiving care management services and high patient or member satisfaction with care management programs
Works collaboratively with nursing, clinical programs, clinical services, compliance, risk management, Chief Medical Office, regional operations, health plans and the community to understand system-wide trends, to improve care and foster an interdisciplinary approach to Integrated Care Management across Intermountain
Stays abreast of changes to the healthcare environment, care management and healthcare reimbursement innovations through local, regional and national networking
Supports best practice through policy standardization, appropriate data collection and analysis, IS support and clinical education collaboration
Leads and supervises care management professionals and is responsible for staffing, performance management and development of that team

133

Care Management Assistant Resume Examples & Samples

Responsible for obtaining “expert” level knowledge of the benefit plans and the contracts with the various insurance plans, Medicare and Medicaid, regarding prior authorization processes, precertification requirements and other functions related to Care Management of patient populations services by DaVita Medical Group. This includes staying abreast of insurance plans in the process of being added, deleted or changed
Responsible for compiling Care Management data and coordinating Care Management data reports as required by DaVita Medical Group’s contracted partners and regulatory agencies
Cross trains in Clinics as needed to maintain up to date knowledge of Clinic front office, back medical office and Electronic Health Record (EHR) processes to ensure appropriate support of the Care Management functions

134

Care Management Liaison Resume Examples & Samples

Information dissemination and education about waiver services
Assist with interviewing prospective participants to determine eligibility for Waiver Services
Track referrals and intakes and manage related databases
Assist with development of Community Resources and Provider networks
Assist with review of all participant service plans
Provide technical assistance to participants, family members and providers

135

Manager, Reg Inpatient Care Management Resume Examples & Samples

Closely monitors and analyzes all inpatient and outpatient reports and identifies trends. Makes recommendations to the Vice President/Director, Regional Care Management regarding interventions to improve all resource management
Provides supervision and guidance to Supervisor and staff reporting to the position
Ability to act professionally under pressure

136

VP, Reg Care Management Resume Examples & Samples

Identifies need for and participates in the development and implementation of care management and utilization management policies and procedures, and ensures compliance throughout the region and consistency throughout the network
Monitors closely and analyzes all inpatient and outpatient reports and identifies trends. Makes recommendations to the Regional Accountable Team (RAT) regarding interventions to improve all resource management
Develops and coordinates strategies for ensuring the delivery of care in the most appropriate setting
Ensures that contracted providers are used and collaborates with Contracting department to obtain new contracts with preferred providers based upon specific quality and utilization criteria
Monitors of all high-risk/high-cost patients in regard to care delivery, referrals, contracting, etc. Oversees cross-regional high-cost areas of Care Management (i.e., transplant or high-volume complex lines of business such as IPA/group)
Monitors provider referral patterns for appropriate utilization of specialty and ancillary services
Initiates organizational and system changes to improve departmental staffing efficiency and effectiveness, and care management program outcomes within the region
Coordinates or performs projects/activities as delegated by organizational committees and Supervisor
Participates and supports organizational committees as appropriate including the Regional Care Management Committees per regulatory guidelines
Identifies, develops and oversees the educational needs of the Care Management providers and staff including the implementation of an extensive orientation program, cross-training and proactive approach to Care management
Identifies opportunities for the development of new care management approaches and prepares proposals with cost analysis, IS requirements, educational needs and implementation plan to be presented to the centralized team for network-wide implementation
Develops and manages regional business plans and budget with RAT
Motivates and leads the Care Management staff in setting and reaching goals for continuous improvement in quality, service and cost-effective care to all HCP customers
Over 5 years and up to and including 7 years of experience
5 years of management experience in a medical group, IPA or HMO setting
Experience in the creation and implementation of outcome measures of new programs
Proficient in Microsoft Office applications
Demonstrated effective management abilities
Ability to work cooperatively with peers and subordinates
Results-oriented

137

RN Care Management Specialist Resume Examples & Samples

The job incumbent is required to demonstrate the knowledge and skills necessary to provide patient care across the lifespan and with the designated population. This requires that the incumbent demonstrates knowledge of the principles of growth and development as well as the physical, emotional and psycho-social needs of the patient population served
Minimum education: Bachelor’s of Science in Nursing (BSN) degree required
Licensure: Current Illinois and/or Michigan RN license or license eligible at time of hire
Minimum experience: Three to five years of experience caring for patients with progressively increasing responsibility. Broad knowledge of chronic illness and medical and community resources required. Demonstrates knowledge in Clinical Outcome Management, Care Environment Management, and Nursing Leadership
Flexible work schedule – weekend/holiday/on call rotation. Requires the ability to successfully use independent judgment and make decisions and requires little supervision
Care Management certification as appropriate for adult or pediatric within 3 years of hire
Working knowledge of a clinical EMR system and Microsoft Office applications
Able to work independently and efficiently with excellent time management skills
Work requires substantial interpersonal skills to develop and maintain cooperative working relationships with personnel from other departments

138

Care Management Assistant Care Coordination Center Maitland Per Diem Resume Examples & Samples

Flexibility in prioritization and effective organizational skills
Professional presentation and decorum aligned with environment in which they are situated
Excellent customer service and verbal and written communication skills
Knowledge of Microsoft Office (Word, Excel and Power Point)
Recent hospital experience (preferred)
Associate’s degree in a healthcare-related field (preferred)

139

Director of Care Management Resume Examples & Samples

Reviews department clinical services and operations, and tracks case management activity. Identifies areas for performance improvement by examining productivity and workload within each department. Directs, coaches, mentors and assesses staff in clinical case management service delivery
Ensures departments achieve institutional visions, goals and objectives by developing scope of service, establishing/maintaining effective relationships with physicians, and collaborating with other disciplines. Assesses goals and utilizes data to effect corrective action
Oversees activities of onsite Case Managers. Presents regular productivity reports, and meets with Case Management staff on an individual basis to discuss targets and other issues of concern
Attends Joint Conference meetings with major payers
Develops relationships and seeks feedback from internal and external stakeholders regarding the implementation of department activities to garner satisfactory customer results
Emphasizes a collaborative approach and seeks to influence other services by focusing on patient processes
Develops and implements Utilization Review (UR) based on internal data collection, data received from external agencies, Physician Advisors and the Medical Director
Ensures Discharge Appeals functions are carried out within contractual, federal and state guidelines. Presents and reviews data relative to avoidable days, denials, length of stay and other key metrics to leadership

140

MSW Care Manager Emergency Dept Care Management Celebration Resume Examples & Samples

Master of Social Work
Ability to function in a stressful and fast-paced environment
Ability to analyze complex interpersonal dynamics in brief time
Significant knowledge and understanding of availability of community and post-acute resources
Clear/Active Licensed Clinical Social Worker (Preferred)
Case Management certification - ACM (Accredited Case Manager), CCM (certified Case Manager) (Preferred)

141

VP, Complex Care Management Resume Examples & Samples

Responsible for driving and executing end to end 4+ Stars/HEDIS strategies for Complex Care Management and HouseCalls
Partner with product and clinical teams to drive best in class Stars/HEDIS performance across all Hplans for all Complex Care markets
Develop and track Stars/HEDIS work plans and strategies for CCM with the Local, Regional and National teams to ensure daily management and execution of 4+ Star results
Ongoing review of data to track real time performance to manage and prioritize local market strategies
Collaborate with the Product team to execute market Hplan strategies that align with the overall CCM business strategy to drive quality and financial results
Business and Strategic Planning
Develop, drive and execute development of short and long range strategies and annual business plans in conjunction with other functional teams, providing insight and recommendations
Partner with Vice President of Strategy on initiatives to drive performance and develop CCM business processes
Track progress against plan, identify any deviations and suggest plans to remediate; provide reports and analysis as required
Partner with Regional Presidents and local health plan Vice Presidents to drive overall business results, utilization, growth, network and expansion strategies
Lead monthly Senior Operating Team strategies and preparations for Complex Care Management
Lead and manage Regional Quarterly Business Reviews with Regional Presidents and Executive Leadership team
Coordinate with each of the respective CCM leaders on expected deliverables, timing and current business updates
4 year degree, advanced degree preferred
10+ years of health industry experience and/or in a large complex matrixed organization experience
10+ years of experience in leadership role
Demonstrated business acumen in financial analysis, reporting and forecasting and solid understanding of operations
Expert at strategic conceptualization both at a local level and enterprise level
Strong analytical skills; has hands-on experience; ability to quickly aggregate and analyze information and draw conclusions
HEDIS/Stars expertise required with experience in driving end to end HEDIS/Stars strategies for Medicare Advantage
Strong communicator; capable of effectively presenting ideas and selling concepts and tactics; excellent writer, proven ability to communicate effectively with executive-levels; ability to quickly understand needs and act on those needs; ability to conceptualize and effectuate change management and 'out-of-the-box' thinking
Proven ability to build relationships cross-functionally and lead toward common goals
Demonstrated leadership and hands-on experience, strong leader and motivator with the ability to mentor talent within the organization; able to provide work direction; able to attract and retain top talent
Strong project management skills; demonstrated history of managing significant and complex projects
Intermediate to advanced MS PowerPoint and Excel skills

142

Care Management Assistant Resume Examples & Samples

1 year administrative or clerical experience
High School diploma or equivalent. experience
Ability to work effectively under pressure due to changing priorities, interruptions, high/low census, payer demands and discharge planning demands
Excellent interpersonal communication, including conflict resolution, problem solving and negotiation skills
Clinical knowledge of multiple age groups, medical illness and treatment plans according to disease process, diagnosis and anticipated LOS
Strong organizational and time management skills, as evidenced by capacity to multi-task and prioritize
Ability to work independently and exercise sound judgment in interactions with physicians, payers, patients and their families
Demonstrates the knowledge and skills necessary to communicate with third party payers to obtain authorization for the appropriate treatment setting for patients requiring medical, psych and chemical dependency treatment
Must be proficient in required competencies upon completion of orientation and maintain annual departmental competency requirements
Ability to work collaboratively regardless of social, economic and cultural backgrounds
Computer skills in using Microsoft Office (Excel, Word, Power Point, Access)
2-3 years administrative or clerical experience in a medical office setting or hospital based environment with patient and family interaction. Knowledge of medical terminology, insurance verification and authorization processes
Bachelors degree in related field
Knowledge of CCS/Medi-Cal regulations and requirements. Knowledge of third party payor requirements in order to optimize reimbursement Bi-lingual

143

Case Management Assistant Care Management Resume Examples & Samples

High-School graduate or equivalent
One-year coding or managed healthcare experience, preferably within an acute healthcare system environment
Self-directed individual with ability to prioritize multiple tasks and meet deadlines, excellent attention to detail, and maintain a high level of work quality
Strong team player with excellent oral, verbal and presentation communication skills
Basic knowledge of medical procedures and terminology

144

Care Management Specialist Resume Examples & Samples

Graduate of an accredited school of Social Work
BSW or MSW or related experience
Knowledge and experience with managed care
One year of case management experience

145

RN Care Management Supervisor Resume Examples & Samples

Directs, plans, and supervises activities and priorities within all areas of the department reporting directly to the Director of Care Management
Collaborates with the Well Med clinic administrator and / or Tier I office administration in assuring processes are in place to accomplish all defined goals of the quality metrics
Coordinates personnel to meet medical management operational program needs in the market as it relates to care management activities
Fosters open communication with Regional Director by acting as care management liaison and clinical resource in the implementation of strategic changes to corporate policies and projects to ensure smooth transition of operations
Communicate both vertically and horizontally regarding UM issues and changes, timely and appropriately. Participates in market meetings and addresses UM issues and changes
Reports to senior leadership on the status of organizational goals within the specified market
Provides monthly operational reports of case management activities to senior management
Monitors care manager’s prospective, concurrent and retrospective assessment, planning, implementation, tracking, monitoring, coordination, reconciliation and evaluation of the managed care members across the continuum of care to include the complete transition of care to outpatient care
Ensures all medical management operations and administrative processes are in place to meet the needs of clinic staff, customers, and patients
Interviews, hires, and retains quality nursing staff to meet the needs of the department
Evaluates nurse performance and recommend merit increases, promotions, and disciplinary actions
Attends, and assists with the facilitation of the weekly PCC meetings at each clinic within assigned territory and participates in committees as requested and monitors team participation and performance during meetings
Monitors and oversees the reporting of all quality issues to UM Medical Director and potentially the Health Plan for accuracy and frequency and ensure staff participation in reporting of quality issues
Assist with physician members in their awareness of preferred contracted providers and facilities
Mentors and serves as an operational resource for care management staff, PHC market providers, internal departments, and external partners regarding customer service issues
Actively participates in process improvement planning and implementation
Exercises cost containment of supplies, travel and overtime etc
Bachelor of Science in Nursing (BSN) required (8 additional years of experience beyond the required years of experience may be substituted in lieu of a bachelor’s degree)
Active Registered Nurse (RN) license in the applicable state
5 or more years of healthcare experience to include experience in a managed care setting, hospital setting and/or physician practice setting
5 or more years experience in managed care and / or disease / utilization management with a minimum of three years at a management level
Data mining, analytical and reporting skills. Must be able to review and interpret data to make recommendations to senior-management

146

Assistant Director of Health Home Care Management Resume Examples & Samples

Bachelor's degree in Healthcare Administration, or a related field required; Graduate degree in Business, Public Health, or Health Administration preferred
5 years of healthcare management level experience or an equivalent combination of education and experience
Previous work experience in clinical setting, population health initiatives or care management highly desired
Strong project management skills, including organization of individual and team work; prioritization; problem solving; adaptability; flexibility; and attention to detail
Proficiency in data analytics
Teamwork, including the ability to draw out diverse perspectives, consider problem resolution from multiple angles, and build upon the experiences of all team members to create solutions that are broadly supported
Exceptional judgment and ability to learn the needs of different components of the UR Medicine Enterprise
Business / financial planning, including the ability to identify and quantify resources needed for successful expansion of the program
Excellent verbal and written communication and interpersonal skills; and
Proficiency with Microsoft Office programs (Outlook, Word, Excel, Access and Powerpoint) and ability to learn new software as needed (Netsmart, eRecord)

147

Care Management Assistant Resume Examples & Samples

Obtains and records authorizations for ancillary services and denial reporting
Facilitates, identifies and documents all referrals, along with patient choice, to appropriate facilities or agencies
Expedites discharges by transmitting appropriate documentation to providers for acceptance of patient. Documents all interactions with payers and communicates status with appropriate staff
Communicates status with Case Management staff and arranges for patient transfer. Functions as a key point of contact between Case Management staff, admissions and payers

148

Senior Care Management Assistant Resume Examples & Samples

Review task note and members’ discharge status to prioritize work schedule
Check members’ eligibility and demographic information
Outreach call to members following Case Management guidelines
Complete weekly and monthly stats
Functions as Preceptor to new Care Management Assistants
Retrieves and processes voice mails and external CM referrals per guidelines

149

Licensed Manager of Care Management Resume Examples & Samples

5-7 years in clinical area of expertise required
Master's degree in behavioral health field; or Registered Nurse (BSN preferred): and Active unrestricted State Licensure in applicable functional area. (eg RN, LPC, LCSW)
Minimum 1-3 years management experience required; demonstrated experience interviewing staff and assessing candidates for hire

150

Case Manager Ii Care Management Resume Examples & Samples

Current license to practice as a Registered Nurse (RN), in good standing, within the State of California
Current American Heart Association Healthcare Provider BLS (CPR) certification
Proven ability to interface with all customer levels (physicians, Organizational staff, insurance companies, patients and family members)
Working knowledge of Microsoft Office Suite, including Outlook, Word, Excel, and PowerPoint, plus healthcare database systems
Decisive and capable of exercising good judgment under pressure

151

Case Manager, Sw Pd Irvine Care Management Resume Examples & Samples

Master’s Degree in Social Work (MSW)
Minimum 1(1) years MSW experience in an acute healthcare setting
Must be able to master detailed and complex information regarding benefits and coordination of care
Demonstrated ability to work on a multidisciplinary team
Demonstrated ability to function independently as a collaborative, supportive team member
Must have solid psychosocial assessment skills
Knowledge of chronic and acute disease and how it impacts patient and family functioning
Decisive and capable of exercising good judgment under pressure. Preferred
Qualified bilingual or multilingual candidates

152

Care Management Clinical Liaison Resume Examples & Samples

Monitors completion of assigned tasks and takes steps to ensure tasks are completed in a timely, efficient and effective manner
Audits for compliance issues related to UR
Responsible for all Medicaid state calls to obtain authorization
Manages remote UR activity
Oversees Data entry of RAC and other third party audit correspondence into tracking tools, delegates to others as appropriate
Assists in developing processes and policies as needed
Provide input and feedback to the organization's Clinical Documentation Improvement program, physicians, case managers, and others as appropriate
Clinical Documentation, coding, insurance or case management experience required
Extensive understanding of Medical Necessity protocols, i.e. Interqual, Milliman Clear, effective communication skills
Computer skills, especially in Microsoft Office products (Word, Excel, PowerPoint)

153

Data Analyst Hcs Care Management Resume Examples & Samples

Work with the vendor and other system users across the country to determine the best way to produce the output UNC needs to facilitate business. They will participate on vendor focus groups to improve the product and they are expected to be a leader of any user groups that are formulated
Review other data sources used by the organization. He/she will determine if this data should be incorporated and if so, will develop an plan to bring the data sources together in the most productive way possible. Once the plan is developed, this position will work independently with constituents to execute the plan
Will manage the relationship with the vendor of the software product
Will work on multiple projects associated with data management for the organization
Will solicit data needs from our clinical department customers to identify information needs. He/she will then work with the disparate groups to gain consensus on what the group as a whole needs, develop plans to meet those needs and then execute those plans to ensure customer satisfaction. Will follow-up with customers to ensure their needs are met
Will also convene meetings with departmental staff to brainstorm needs related to staff productivity. He/she will develop plans to meet these needs and execute those plans
Will assist in developing staff benchmarks for productivity and ultimately will be able to prepare staffing models

154

Care Management Specialist Resume Examples & Samples

Collaborate with the Physician for assignment of appropriate level of care and safe patient discharges
Be responsible for the improvement and risk management review of patient care using objective criteria, evaluation of utilization of hospital resources for appropriateness of care, and supporting the care of the patient by assisting the clinical care givers in planning and providing for post discharge resources and services for an assigned patient population
Assist the physicians and health information records services coders in assuring medical- legal compliance with documentation requirements in the medical record through concurrent review and analysis of the medical record for an assigned patient population in planning, implementing, and evaluating the patient plan of care
Minimum of 3 years hospital clinical nursing experience required
Graduate of a NLN accredited school of nursing required; BSN required

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