Under general supervision, responsible for achieving overall clinical performance goals through day to day direction of the designated clinical care team, coordinating operational processes, monitoring performance to achieve consistent process standards and metrics through quality assessments, training, and improvement tactics, and in compliance with regulatory, NCQA and other applicable standards. Work is varied and moderately complex, and requires a limited to moderate degree of discretion and independent judgment.
- Monitors daily workflow including incoming referrals, caseloads and acuity management to meet clinical care and production standards and to achieve established process measures.
- Works in collaboration with the supervisor to identify and implement consistent work processes to achieve compliance standards and continuous operational readiness.
- Provides subject matter expertise within the team for clinical care services and works closely with team members in daily review processes.
- Performs telephonic and onsite outreach to members to determine member needs and works with hospital care management to develop discharge plans.
- Conducts internal audits as directed and according to established tools and criteria; provides feedback to supervisor; takes actions as directed.
- Tracks and trends performance, identifies any gaps and root causes, reports and, based on audit results, recommends improvement opportunities to management.
- Prepares for and participates in regulatory audits including gathering information, reporting and developing and monitoring corrective action plans.
- Provides training to new employees based on established guidelines; provides; coaches, trains, and conducts follow up as directed for team and individual performance improvement.
- May assist with the recruiting and selection process.
- Maintains training manual and desk top procedures, and other documents as required.
- Strong clinical skills as an RN as defined in California scope of practice guidelines.
- Strong knowledge and current NCQA standards; researches and remains current with a federal and state laws and regulations.
- Strong knowledge of federal and state laws, standards and regulations, including Medi-Cal and/or Medicare and HIPAA, in managed care organizations.
- Strong knowledge of and proficient skills in administering protocols.
- Ability to read and apply clinical information, practice guidelines and other complex data and information.
- Produces work that is accurate and complete.
- Produces the appropriate amount of work.
- Actively learns through experimentation when tackling new problems, using both successes and failures to learn.
- Rebounds from setbacks and adversity when facing difficult situations.
- Knows the most effective and efficient process to get things done, with a focus on continuous improvement.
- Ability to design workflow and procedures.
- Strong knowledge of audit processes, and the ability to effectively implement and maintain them.
- Strong problem-solving and analytical skills, with ability to determine key issues, develop effective actions plans and implement to successful conclusion.
- Ability to handle confidential information with appropriate discretion.
- Time management and organizational skills. Uses time effectively and efficiently. Values time. Concentrates his/her efforts on the more important priorities. Can attend to a broader range of activities. Meets deadlines.
- Interpersonal skills - interacts effectively with individuals both inside and outside of HPSJ; relates openly and comfortably with diverse groups of people.
- Ability to define problem(s), collects data, establish facts, and draw valid conclusions.
- Strong oral and written communication skills with the ability to communicate with diverse individuals inside and outside of HPSJ, effectively explain complex information, do presentations, and document according to standards.
- Strong listening skills, with the ability to accurately receive and understand messages.
- Basic leadership skills, including but not limited to the ability to influence without authority and motivate others.
- Commitment to and ability to facilitate the adoption of HPSJ’s strategy, vision, mission and values.
- Basic conflict resolution skills, with the ability to use tact and diplomacy to diffuse emotional situations.
- Strong facilitation skills, with ability to manage discussions among individuals from a variety of areas and levels to successful conclusion.
- Strong customer service skills.
- Ability to develop and deliver relevant and effective training and supporting materials.
- Ability to enter data into and navigate through multiple databases.
- Intermediate skills in Word, Excel and Outlook.
- Demonstrated ability to supervise staff in a manner that maximizes employee performance and business results.
- Ability to speak and be understood in English.
- Associate Degree in Nursing; and
- At least one year of clinical experience in acute Inpatient or long-term care.
- Bachelor’s Degree in Nursing
- Case management and/or TOC experience
- Utilization Management experience with MCG Criteria
- Current and valid unrestricted California RN nursing license.
- Valid California driver license and reliable transportation or, the ability to obtain transportation on demand in the counties served by HPSJ if prohibited from getting a driver license due to a medically documented disability.
- Current Certified Case Manager (CCM)
- California Certified Professional Utilization Management