Community Health Group is a locally based non-profit health plan that ensures access to high quality, culturally sensitive health care for underserved communities throughout San Diego County. We treat our 300-member, multi-lingual staff like family, encouraging an atmosphere of collaborative teamwork, continuous learning, personal growth, and promotion from within. Recognized as one of the Top Workplaces in San Diego, CHG offers its employees such benefits as tuition reimbursement, a meditation room and yoga classes, a monthly Breakfast With The CEO, and memorable events throughout the year.
We know that by serving our employees well, they, in turn, will better serve our nearly 250,000+ membership. We have been recognized consistently for the excellence and sensitivity of our customer service by members, physicians, vendors, and a full range of health care providers. We are accredited by the National Committee for Quality Assurance and proud of our continuing company-wide Quality Initiatives.
We are currently recruiting for:
TITLE: Director of High Risk Case Management
The Director of Case Management provides direction to Community Health Group’s (CHG’s) high risk case management program and is responsible for the optimal and timely delivery of proactive and collaborative case management and care coordination for high risk, complex CHG members along the entire continuum of care. He/she assesses, plans, organizes, enhances, implements and evaluates the case management program and care coordination activities.
COMPLIANCE WITH REGULATIONS
Works closely with all departments necessary to ensure that the processes, programs and services are accomplished in a timely and efficient manner in accordance with CHG policies and procedures and in compliance with applicable state and federal regulations including CMS and/or Medicare Part D, DHCS and DHMC.
- Develop and implement processes, policies, and procedures to meet the evolving goals and requirements of the high risk case management program.
- Manage, train, develop, and motivate the case management and care coordination staff to accomplish program goals and objectives.
- Prepare and evaluate monthly, quarterly and annual reports to demonstrate program performance.
- Oversees the management and care coordination of identified high risk members to reduce recurrent and unnecessary hospital admissions, readmissions, and emergency room visits. Oversees the process to promote smooth transitions of care for targeted members. Facilitates the coordination of comprehensive or multi-faceted care plans for identified members.
- Coordinates individually needed interventions for select members based upon CHG established indicators.
- Provides guidance to case managers and care coordinators with difficult cases and situations; assumes responsibility of cases when risk management issues are identified.
- Triages requests for case management and care coordination services and fosters an equitable case distribution among staff.
- Forwards quality of care concerns to the Corporate Quality Department using criteria for identification of these cases, assist with QI studies and provides case-specific follow-up on an as-needed basis.
- Reviews policies, procedures and workflow at least annually.
- With the Health Care Services management team, works to develop, implement, and evaluate interventions designed to enhance member outcomes, quality metrics, and increase customer satisfaction.
- Functions as a resource to internal and external customers.
- Graduate from an accredited school of nursing and active CA RN license or,
- Masters in related health care field
- 5 years’ experience directing or managing a high risk case management program in a hospital or managed care setting preferred.
- Strong leadership and organization skills required.
- Knowledge of population health, care/case management clinical operations, and management expertise relating to business planning, process improvement, budget administration, and personnel management.
- Working knowledge of Microsoft programs; proficiency with Word and Excel.
- Knowledge of managed care principles, CPT, ICD-9, HCPCS coding, experience with inpatient and outpatient medical review guidelines (MCG).
- Familiar with Medi-Cal, Medicare. Familiar with Web based standard of care sites i.e. NIH, ACOG.
- Ability to communicate effectively verbally and in writing; exceptional telephone and customer service skills; ability to establish effective working relationships with physicians and medical professionals;
- May be required to conduct in-person visits and assessment of members.
- Prolonged periods of sitting at desk; intermittent standing, walking and bending.
- May be necessary to work and attend meetings outside of facility or normal business hours.
- Lifting 10 lb. or less.
- Driving within County of San Diego
- California driver’s license in good standing.