AmeriHealth Caritas Delaware is excited to have been chosen as one of the Medicaid managed care plans for the Diamond State Health Plan and Diamond State Health Plan- Plus programs. Backed by a national organization, we have long-term experience serving the Medicaid population in neighboring states. We are committed to delivering health care through innovative services and programs and are looking forward to helping Delaware become an even healthier state.
Responsible for providing oversight and administrative management of the Care Management Department and related teams, care plan development, and care plan implementation.
Direct activities of the Care Management staff. Oversee staff performance with regard to prior authorization, medical necessity determinations, concurrent review, retrospective review, continuity of care, care coordination, and other clinical and medical management programs. These responsibilities extend to physical and behavioral health care and transportation services.
Ensure effective daily operation of the Care Management Department utilizing all applicable statutory provisions, contracts and established policies and administrative procedures.
Maintain optimal staffing patterns based on contractual obligations and current Care Management budget. Comply with all policies and procedures for personnel requisitions, interviews and employment. Maintain accurate position control and organizational chats of assigned departments..
Partake in internal pharmacy therapeutic committee and work closely with the Directors of Pharmacy, pharmacy benefits manager (PBM), and the State’s PBM team.
Prepare reports and conduct analysis of operations / services as required by departmental, corporate, regulatory, and State requirements. Work collaboratively with Information Services Department on identifying required data for reporting.
Assist in preparation, coordination, and follow up of Care Management audits, such as readiness review and site visits, pertaining to the Care Management Department.
Partner with community agencies and contracted vendors to develop and maintain collaborative contact to assure members have access to the appropriate resources and to avoid duplication of efforts.
Act as a liaison with outside entities, including but not limited to physicians, hospital, health care vendors. social services agencies, member advocates, and other entities.
Participate in coordination of internal and external Provider and Member directed communication regarding issues impacting Care Management coordination and delivery, such as medication management, use of generic medications, etc.
Establish performance and productivity requirements and communicate expectations to management team. Work collaboratively with Supervisor in identification of individual and / or group deficiencies in scheduled Performances Reviews. Establish action plan for assessment and resolution of identified issues.
Oversee the collaborative efforts of the Supervisors to ensure that all new and existing staff are oriented to organizational and department policies and procedures. Ensure that credentials of all licensed staff are verified in accordance with licensing agency initially and prior to expiration date. Maintain current and accurate files of such licensure and ongoing education status. Ensure that staff meets minimal skill and clinical knowledge requirements to be successful in assigned role.
Participate in current process review and development of new and / or revised work processes, policies and procedures relating to Care Management responsibilities. Provide input into the development of educational material and programs necessary to meet business objectives, members’ needs, contractual and regulatory guidelines and staff professional development.
Comply with Corporate, Federal, and State confidentiality standards to ensure the appropriate protection of member identifiable health information.
Develop and maintain department budget. Seek opportunities to contain cost.
Current unrestricted RN Licensure in the state of Delaware required.
Three years case management experience in relevant scope preferred, one year required
Case management certification preferred, those seeking case management certification considered
Professional certification in a clinical specialty needed
Experience in use of financial information for planning purposes
Valid Driver’s license and clean driving record required; reliable transportation and appropriate auto insurance necessary
Demonstrated ability to assess department’s work quality and develop/implement process improvements to achieve contractual and oversight compliance.
Maintain a current knowledge of company policy and procedures, NCQA/URAC recommendations impacting Care Management assessment, access and delivery of services. Maintain understanding of managed care and Care Management role and impact on services including but not limited to, prior authorization, inpatient review, discharge planning, home health, and SNF/Rehabilitation Services.
Demonstrated competency in use of healthcare data.
Excellent analytical and problem solving skills
Strong computer skills. Proficiency and speed working in all Microsoft office Suite applications
Experience working with the aged, blind, and/or disabled population strongly desired
Fluency in a second language desired
Understanding of and expertise in quality improvement and medical economics.
Leaders in health care solutions for those most in need
AmeriHealth Caritas is the nation's leader in providing comprehensive health care solutions for those in most need and the chronically ill. We impact the lives of more than 5.7 million members nationwide. With more than 30 years of experience managing care for individuals and families in publicly-funded programs, we have become known for d...eveloping innovative solutions that help improve health outcomes while reducing costs.
Our mission, our goal
Our mission is to help people get care, stay well and build healthy communities. Our goal is to provide responsible managed care solutions, including Medicaid, Medicare, and CHIP - plus behavioral health, pharmacy benefits management and third-party management and administrative services.
Through outreach and grassroots advocacy, we develop a firm understanding of the unique health care needs of each community we serve. This allows us to customize our programs to best improve the health of those who call the community home.
At every step of the way, we make it a point to keep care at the heart of our work - just as we have for the past three decades.