Manager, Case Management

Houston

Job Description Job Description Summary

The purpose of the Manager, Case Management position is to support the case management functionality in the organization. The department is responsible to integrate and coordinate resource utilization management, care facilitation and discharge planning functions. In addition, the department helps to drive change by identifying areas where performance improvement is needed (e.g., day to day workflow, education, process improvements, patient satisfaction). The position is responsible for direct oversight of the team and their activities, auditing documentation, and analyzing reports and data.

Essential Functions include the following. Other duties may be assigned. Day to day oversight of the case management department and staff

Works collaboratively and maintains active communication with physicians, nursing and other members of the multi-disciplinary care team to effect timely, appropriate patient care.

Addresses/resolves system problems impeding diagnostic or treatment progress.

Collaborates with internal and external partners to identify and remove barriers to improved member outcomes, including medical, behavioral and social needs.

Utilizes advanced conflict resolution skills as necessary to ensure timely resolution of issues.

Audits clinical documentation for compliance and quality

Analyzes reports and data regarding productivity, caseload, throughput, unable to contact and other metrics and communicates findings and recommendations to the director

Collaborates with medical staff, nursing staff, and ancillary staff to eliminate barriers to efficient delivery of care in the appropriate setting.

Identifies at-risk populations using approved screening tool and follows established reporting procedures.

Refers cases and issues to Care Management Medical Director in compliance with Department procedures and follows up as indicated.

Organizes the team and cases for case management rounds with the medical director and multidisciplinary team.

Coordinates and provides onboarding and education for the case management team

Assists in development of new hire orientation schedule and helps identify individual needs for learning.

Uses data to drive decisions and plan/implement performance improvement strategies related to case management for assigned patients, including fiscal, clinical and patient satisfaction data.

Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency; ​​​​supports department-based goals which contribute to the success of the organization; serves as preceptor, mentor and resource to less experienced staff.

Experience with NCQA and CMS audit standards required

In collaboration with the Director, develops, implements and monitors work flow processes, policies and procedures

Evaluate case management program effectiveness and develop recommendations for improvement

Experience in medical and behavioral case management preferred

Other duties as assigned.

Candidate Qualifications

Education Current and valid license to practice as a Registered Nurse in the state of Texas or Compact state, BSN preferred

Current and valid license as a Master Social Worker (LMSW) in the state of Texas required, LCSW preferred

Experience Five (5) years combined strong clinical experience and management of clinical

functions required

Three years of managed care experience, preferably in Medicare Advantage or

Medicaid government programs, required

Minimum 1-year supervisory experience

Experience in utilization management, case management, discharge planning or other cost/quality management program preferred

Experience with NCQA, CMS and/or Texas Department of Insurance required

Skills Excellent interpersonal communication and negotiation skills

Demonstrated leadership skills

Strong analytical, data management and PC skills

Current working knowledge of discharge planning, utilization management, case management, performance improvement, disease or population management and managed care reimbursement

Understanding of pre-acute and post-acute venues of care and post-acute

community resources, physician office routines, and transitional procedures for pre- and post-acute care.

Demonstrated understanding of motivational interviewing and change management.

Strong organizational and time management skills, as evidenced by capacity to prioritize multiple tasks and role components

Ability to work independently and exercise sound judgment in interactions with physicians, payors, and patients and their families

Effective oral and written communication skills

Technical Skills

Proficient in Word, Excel, Tableau and PowerBi reports and case management

software

Supervisory Responsibilities

Day-to-day management of Case Management Department staff, including

interviewing, performance monitoring of individual and department metrics, staff

development and coaching and development, monitoring and execution of

performance improvement plans.

About Apex Health Solutions

Apex Health Solutions powers payers and providers choosing to engage in

value-based risk contracting. Apex’s unique solutions create alignment

between payers and providers, generating unparalleled value. Combined

with Apex’s experienced and successful industry leadership, our focal

point remains on improvement in patient quality, satisfaction and overall

cost of care