Summary
Job Summary
Responsible for planning, developing, organizing, directing, and implementing a coordinated approach to case management and disease management services for members in order to meet any obligation of contractual agreements and legislative regulations (i.e. HHSC, TDI, CMS, URAC). Accountable for ensuring effective processes, policies, and procedures that promote the integration of the member’s holistic needs, thus resulting in cost-effective, quality care with a focus on member-centered, strength-based interventions for beneficiaries covered under each line of business. Ensures current knowledge permeates in the Case Management and Disease Management units to promote inpatient and outpatient decisions that are consistent with the health plan’s medical management function.
Skills
1. Leadership ability, communications, and interpersonal skills necessary to interact effectively with physicians, management, staff, and external agencies/customers.
2. Solid organization and contract management skills.
3. Excellent analytical and negotiation skills.
4. Excellent oral and written communication, interpersonal and time management skills.
5. Ability to execute and be a self-starter and follow through on projects.
6. Possess expertise in Microsoft Excel, Power Point and Microsoft Word.
7. Strong computer skills, including familiarity with database systems.
Work Experience
Three years of management/supervisory experience required. Strong experience in a managed care environment. Experience with Medicare, Part D, and/or other government programs preferred. Experience with data collection and analysis, and designing reports, as demonstrated by work experience preferred.
License/Registration/Certification
Must have an active and unrestricted Texas license if a Registered Nurse, Social Worker or Professional Counselor.
Certified Case Manager (CCM) preferred.
Education and Training
Bachelor degree in Nursing or Social Work required.