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Leader, Care Management Special Needs Plan

Company: MVP Health Care
Location: Rochester
Posted on: June 10, 2021

Job Description:

Leader, Care Management Special Needs Plan
Headquarters Office, 625 State Street, Schenectady, New York, United States of America

  • Rochester Office, 220 Alexander Street, Rochester, New York, United States of America
  • Tarrytown Office, 303 South Broadway, Tarrytown, New York, United States of America Req #786

    Tuesday, April 27, 2021

    Be a part of the transformation at MVP Health CareĀ®. MVP Health Care is a nationally-recognized, regional not-for-profit health insurer. We care for more than 700,000 members across New York and Vermont and are powered by the ideas andenergy of more than 1,700 employees.We employ talented people with diverse backgrounds and experience-tech people, numbers people, even people people-to make health insurance more convenient, more supportive, and more personal. If you're ready to join a thriving, mission-driven company where you can create your own opportunities-it's time to make a healthy career move to MVP.

    Status: Full-time, Exempt

    The Leader is responsible for leading the development and quality of clinical programs in association with the Medical Director.The Leader will coordinate clinical initiatives with colleagues in the Dual Special Needs Plan (DSNP).The Leader will be responsible for implementing clinical services, care management, disease management programs, and quality initiatives for all program members including but not limited to those with medical, behavioral, physical, intellectual, or developmental disabilities.

    Essential Functions/Responsibilities:

    Direct clinical and care management programs and support services that will promote the highest standards of quality and appropriate services to members of the DSNP.

    Collaborate with the Medical Director to develop, implement, and monitor performance standards for clinical services and care management and fidelity to the model of care.

    Createaclimate that motivates case and disease management staff to do their best. Emphasizes the importance of individuals' contributionstotheteam'ssuccess.

    Participate with MVP leadership in developing goals, strategies and management practices that will ensure growth, development, and financial success.

    Develop strategies to engage providers in the care model to which we are committed and identify those providers who are collaborative.

    Recruit, train, develop and maintain a high-quality clinical team of care management professionals.

    Plan,develop,implement,andevaluateprocessesandguidelinesformanagingcareacrossthehealthcarecontinuumforMVPHealth
    Care members enrolled in our programs. Ongoing monitoring, evaluation, and revision of diagnostic and utilizationtriggersandstratificationcriteriaused to identify appropriate members for intervention.

    Oversee the development and implementation of various tools that in corporate peer reviewed clinical guidelines represent "best" practices".

    Provide consultation to Quality Improvement, Utilization Management initiatives in association with Medical Director and MVP leadership.

    Collaborate with the Network team to develop relationships with providers to grow membership.

    Work with external services providers and primary clinical providers to assess and meet members' care and service needs.

    Work with the Medical Director to implement a person-centered, goal-oriented care model across the continuum in conformance with the model of care and state and federal requirements.

    Work with the Medical Director and Network Management to identify strengths and weaknesses of the provider network and develop appropriate strategies to address gaps and assure network optimization.

    Oversee the administration of members' benefits according to MVP's DSNP policies and procedures in all care settings, including service authorization and referral policies, hospital admission and discharge protocols, ancillary services management, and assessment of benefit exceptions.

    Prioritize opportunities for optimal member health, safety, independence, and well-being including management strategies based on membership needs and characteristics that will improve member health outcomes.

    Facilitatesandcoordinatesdevelopment,implementationandevaluationofkeycaremanagementfunctions and processes. Workscollaborativelywithothermanagementteamsacross MVP that includes strategic business units (SBUs), Medical Directors and other internal staff to ensure integration ofkeyfunctionsandprocesses.

    Works with MCO and Operations teams on building clinical systems to support clinical care and data reporting needs.

    Participate in QI Committee, Clinical Operations Committee, and other Committees as defined.

    Performsotherdutiesasassigned.


    Position Qualifications


    Minimum Education

    Clinical professional registered nurse with bachelor's degree in Nursing required. Active professional New York State License required.

    Master's Degree in Nursing, Health Care Management, MBA, or related field, strongly preferred

    CurrentCCMCertificationand/orWellCoachingCertification is an asset

    Minimum Experience:

    5+ years' experience in nursing management role with an emphasis in care management and coordination required

    5+ years management/ supervisory experience in managed care/health insurance with clinical and non-clinical staff required

    3-5years'managed care experience incase,diseaseorutilizationmanagementrequired

    Experience in working with a Medicare and Medicaid underserved populations special needs population required

    Working knowledge of Performance, Process and outcome measures and ability to identify, implement and manage successful processes

    Experience in working with intellectual and developmentally disabled populations preferred

    Experience with NCQA accreditationand/or CMS/DOH audit process preferred.


    Required Skills:


    Ability to interpret and analyze data necessary to identify trends, evaluate trend impacts operationally, fiscally and from a quality perspective and development and managed corrective action activities

    Familiarity with Medicare and State Medicaid programs and hands-on experience with regulatory requirements and reporting.

    Familiarity with utilization management process: current, concurrent, prospective, and retrospective review

    Demonstrated experience in managing clinical nursing staff including recruitment, education, and training

    Excellent communication and relationship development skills with health professionals and business colleagues

    Strong leadership, relationship building, and mentoring skills.

    Abilitytoworkindependentlyandprioritizemultipleassignmentstomeetdeadlines

    Highlyeffectiveinterpersonalandconflictmanagementskills

    Abilitytousediscretioninhandlingconfidentialinformation

    Excellentoralandwrittencommunicationskills

    OrganizationalandTimeManagementskills

    ExcellentCustomerService

    Stronganalyticalandcriticalthinkingskills

    Knowledgeofprocessdevelopment,systemsmanagement,policydevelopmentand workflow design

    Knowledgeofchronichealthconditions,evidence-basedpracticeguidelinesandclinicaltoolsused todemonstratecompliancewithpracticerecommendations

    Provensuccessinteractingwithsensitivehealthissues,medicalnecessity,andserviceappropriateness

    Proficientintheuse/applicationofstandardcomputerapplications(Word, Access, Excel, PowerPoint)

    Valid NYS Driver's license with capacity to travel and reliable transportation

    #LI-CV1

    MVP Health Care is an Affirmative Action/ Equal Opportunity Employer (PDF). We recruit, employ, train, compensate, and promote without regard to race, religion, creed, color, national origin, age, gender, sexual orientation, marital status, disability, genetic information, veteran status, or any other basis, e.g., Pay Transparency (PDF), protected by applicable federal, state or local law. Any person with a disability needing special accommodations to the application process, please contact Human Resources at hr@mvphealthcare.com .

    Other details
  • Job Family Medical Management/Clinical
  • Pay Type Salary

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  • Headquarters Office, 625 State Street, Schenectady, New York, United States of America
  • Rochester Office, 220 Alexander Street, Rochester, New York, United States of America
  • Tarrytown Office, 303 South Broadway, Tarrytown, New York, United States of America

Keywords: MVP Health Care, Rochester , Leader, Care Management Special Needs Plan, Other , Rochester, New York

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