Dec 07, 2019
WellCare Health Plans
Supervises clinical review team members, ensures appropriate workload distribution and oversees day to day workflow processes. Acquires team monthly insights for improvement, develops insight tracking and delivery, and leads Interrater Reliability meetings. Continuously develops performance review tools to ensure validity of criteria, and appropriately captures evidence of expected clinical performance within contractual and Model of Care standards and produces optimal clinical and resource outcomes. Compiles and presents performance review trends and actively participates in department initiatives and projects. Trains team members in the review process for clinical performance. Essential Functions: Assists management in collaborating with Population Health Solutions, Operations and Information Technology departments to ensure full integration of reporting. Monitors associate performance and conducts counseling/corrective action procedures when required. Identifies concerns, brings issues to management's attention and offers suggestions for improvement. Provides significant input to performance evaluation, hiring and termination decisions for associates in work group. Reviews time records, sets schedules and approves all vacation/time off requests for subordinate associates. Provides training and guidance to new and current reviewers regarding policy & procedure, systemic tools, workload and development. Answers all questions and assists peers and management with delegated tasks or projects. Takes the lead in preparing and submitting projects, reports or assignments as needed to meet department initiatives and/or objectives. Leads in the development and ongoing review of clinical review tool to ensure that clinical elements accurately capture adherence with required performance standards. Reviews Care Management program descriptions, policies and procedures, step actions, and training materials as well as State Contracts when needed to evaluate alignment of review tool elements, departmental processes, staff training, and contractual/departmental standards. Utilizes clinical knowledge and experience to evaluate documentation of member health assessments, clinical needs and interventions in meeting compliance standards. Participates in meetings with Care Management and others to discuss review findings, areas of opportunity and recommendations for improvement. Appropriately escalates areas of concern identified during clinical file reviews. Participates as needed with preparation for State, CMS, and NCQA audits by collecting and /or reviewing clinical areas of relevance. Meets established productivity and IRR standards for file reviews. Follows departmental guidelines and processes. Creates Monthly Case Assignment List for Clinical team through regular roster verification Facilitates and organizes regular training IRR meetings for new Clinical team members Presents data findings to Clinical leadership Develops and Maintains Audit Reference Guide and Job Aids for clinical team members Records and tracks productivity for clinical team to report to manager on monthly basis Ensures completion of clinical team assignments through tracking and data compilation Conducts Care Management (UM, BH, CM, and/or DM) performance reviews by reviewing clinical documentation as assigned for Care Management for required clinical adherence as needed Other duties as assigned Additional Responsibilities: Candidate Education: Preferred A Bachelor's Degree in Nursing, Clinical Social Work/Counseling Candidate Experience: Required 3 years of experience in Managed Care (UM, BH, CM, or DM) Preferred Other Familiarity with Medicare and Medicaid programs Candidate Skills: Intermediate Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions Intermediate Ability to effectively present information and respond to questions from peers and management Intermediate Other Detailed understanding of the Medicare and Medicaid rules and regulations Intermediate Ability to work independently Intermediate Demonstrated time management and priority setting skills Intermediate Ability to work in a fast paced environment with changing priorities Intermediate Ability to drive multiple projects Intermediate Demonstrated written communication skills Intermediate Demonstrated interpersonal/verbal communication skills Intermediate Ability to create, review and interpret treatment plans Intermediate Demonstrated negotiation skills Intermediate Ability to lead/manage others Intermediate Knowledge of healthcare delivery Intermediate Other Knowledge of NCQA, CMS, and state Medicaid requirements Advanced Ability to effectively present information and respond to questions from families, members, and providers Intermediate Ability to effectively present information and respond to questions from peers and management Intermediate Ability to implement process improvements Intermediate Ability to analyze and interpret financial data in order to coordinate the preparation of financial records Licenses and Certifications:
A license in one of the following is required: Preferred Licensed Registered Nurse (RN) Preferred Licensed Practical Nurse (LPN) Preferred Licensed Certified Social Worker (LCSW) Preferred Licensed Marital and Family Therapist (LMFT) Preferred Licensed Mental Health Counselor (LMHC) Technical Skills: Required Intermediate Microsoft Outlook Required Intermediate Microsoft Word Required Advanced Microsoft Excel Preferred Intermediate EMMA Languages: About us Headquartered in Tampa, Fla., WellCare Health Plans, Inc. (NYSE: WCG) focuses primarily on providing government-sponsored managed care services to families, children, seniors and individuals with complex medical needs primarily through Medicaid, Medicare Advantage and Medicare Prescription Drug Plans, as well as individuals in the Health Insurance Marketplace. WellCare serves approximately 5.5 million members nationwide as of September 30, 2018. WellCare is a Fortune 500 company that employs nearly 12,000 associates across the country and was ranked a "World's Most Admired Company" in 2018 by Fortune magazine. For more information about WellCare, please visit the company's website at www.wellcare.com. EOE: All qualified applicants shall receive consideration for employment without regard to race, color, religion, creed, age, sex, pregnancy, veteran status, marital status, sexual orientation, gender identity or expression, national origin, ancestry, disability, genetic information, childbirth or related medical condition or other legally protected basis protected by applicable federal or state law except where a bona fide occupational qualification applies. Comprehensive Health Management, Inc. is an equal opportunity employer, M/F/D/V/SO.
Professional Diversity Network
Detroit, MI, USA