We offer remote work opportunities (AK, AR, AZ, CA, *CO, FL, *HI, IA, ID, IL, KS, LA, MD, MN, MO, MT, NE, NV, NM, NC, ND, OK, OR, SC, SD, TN, TX, UT, VA/DC, *WA, WI & WY only).
Our Department of Defense contract requires US citizenship and a favorably adjudicated DOD background investigation for this position.
Veterans, Reservists, Guardsmen and military family members are encouraged to apply!
Job Summary
Responsible for leading and managing a team of clinical and non-clinical staff in providing benefit administration, prior authorization and care coordination TRICARE beneficiaries eligible for ECHO benefits and the Autism Care Demonstration. Under direction from the Director of Case Management (CM), the Manager develops and implements program components to optimize CM and Care Coordination strategies and goals, and policies and procedures to ensure compliance with contract standards.
Education & Experience
Required:
- Registered Nurse, with current unrestricted license
- Bachelor's degree in a health-related field with 3 years Medical-Surgical Clinical experience or equivalent
- If supporting TRICARE contract, must be a U.S. Citizen
- If supporting TRICARE contract, must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation
- Minimum of five years clinical experience with progressively responsible management experience in CM or Care Coordination operations and program development
Preferred:
- Medical Claims, Utilization or Case Management experience
- Clinical Experience related to children with disabilities, TRICARE ECHO and/or Autism Care programs
Key Responsibilities
- Direct operational leadership of CM Specialty Program functions and staff to ensure compliance with contract requirements and adherence to contract deliverables.
- Monitors day-to-day operations of the CM Specialty Program team to identify barriers to providing excellent service to beneficiaries.
- Systematically evaluates the quality and effectiveness of staff performance, analyzing appropriate data and information to identify areas of improvement; advises and coaches when appropriate and completes annual performance appraisals.
- Manage activities necessary to ensure appropriate utilization of resources while maintaining optimal achievable standards of care.
- Participates in the development of measurable outcomes, ensures measures are in place to monitor the impact of programs and services on the health status of beneficiaries being managed.
- Plans and implements orientation and training of new-hire employees.
- Ensure adherence to accreditation standards, contract policy, contractual requirements, and nationally recognized practice standards.
Participates in development of desk procedures, education and auditing to support uniform application of programs and compliance with program policy and standards.- Participates in interdepartmental committees and/or workgroups that are pertinent to areas of responsibility.
- Performs other duties as assigned.
Competencies
Communication / People Skills: Ability to influence or persuade others under positive or negative circumstances; adapt to different styles; listen critically; collaborate. Customer-focused behavior; helping approach, including listening skills, patience, respect, and empathy for another's position.
Computer Literacy: Ability to function in a multi-system Microsoft environment using Word, Outlook, TriWest Intranet, the Internet, and department software applications.
Delegation Skills: Provide clear performance expectations for projects and ensure adequate access to resources for completion.
Independent Thinking / Self-Initiative: Critical thinkers with ability to focus on things which matter most to achieving outcomes; commitment to task to produce outcomes without direction and to find necessary resources.
Information Management: Ability to manage large amounts of complex information easily, communicate clearly, and draw sound conclusions.
Leadership: Successfully manage different styles of employees; provide clear direction and effective coaching.
Multi-Tasking / Time Management: Prioritize and manage actions to meet changing deadlines and requirements within a high volume, high stress environment.
Organizational Skills: Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; detail-oriented.
Problem Solving / Analysis: Thorough knowledge of health care delivery, UM, CM, managed care concepts, management reporting tools, and medical management systems; ability to perform critical, in-depth analysis of medical records for appropriateness and level-of-care determinations.
Team-Building / Team Player: Influence the actions and opinions of others in a positive direction and build group commitment.
Technical Skills: Knowledge of TRICARE policies and procedures, Case Management, Utilization Management, Managed Care concepts, Behavioral Health practices and principles, Medicaid and Medicare eligibility requirements and benefits, community resources, alternative funding programs, medical management systems, and protected health information; proficiency with the use of medical necessity criteria to evaluate care requests; working knowledge of medical coding.
Working Conditions
Working Conditions:
- Availability to cover any work shift
- Remote work environment, with minimal travel required
- Extensive computer and telephone work with long periods of sitting
