Clinical Program Oversight RN D-SNP, Bakersfield, CA

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Clinical Program Oversight RN D-SNP

KHS Family Health Care, Bakersfield, California, United States of America Req #2645

We appreciate your interest in our organization and assure you that we are sincerely interested in your qualifications. A clear understanding of your background and work history will help us potentially place you in a position that meets your objectives and those of the organization. Qualified applicants are considered for positions without regard to race, color, religion, sex (including pregnancy, childbirth and breastfeeding, or any related medical conditions), national origin, ancestry, age, marital or veteran status, sexual orientation, gender identity, genetic information, gender expression, military status, or the presence of a non-job related medical condition or disability (mental or physical).

KHS reasonably expects to pay starting compensation for the position of Clinical Program Oversight RN D-SNP in the range of $45.02 - 57.41 hourly.

*Hybrid Position*

About us

Kern Health Systems (KHS) is dedicated to improving the health status of our members through an integrated managed health care delivery system.

About the role

The Clinical Program Oversight RN D-SNP (Dual Special Need Plan) is responsible for the health care management and coordination of care for members with complex and chronic care needs in alignment with D-SNP program requirements as outlined in the KHS Model of Care. This role involves monitoring activities to support the timeliness of Health Risk Assessment (Initial and Reassessment) completion, Individualized Care Plan (ICP) development and Interdisciplinary Care Team (ICT) delivery for all D-SNP members. This position is responsible for ensuring high quality delivery of clinical support services to our members by monitoring and reporting clinical program performance, with a special focus on vendor performance of contracted clinical activities including but not limited to utilization management, care coordination, and California Integrated Care Management activities.

Essential Duties and Responsibilities

• Assist the Director of Delegation Oversight in managing D-SNP performance and ensuring compliance with CMS/DHCS requirements.
• Aids in the creation, monitoring and reporting of program performance identifying potential opportunities and gaps to ensure the effective delivery of the D-SNP program.
• Participates in D-SNP quality audits, including CMS program audits and vendor audits to assess the timeliness of D-SNP activities. Reports audit results and identifies opportunities for process improvements
• Effectively communicates and keeps Director of Delegation Oversight informed of all clinically related operations, activities, data, program performance, issues, or any other pertinent information that would impact the over-all compliance or achievement of internal goals.
• Assists with patient tracking, data reporting, and vendor management.
• Manages and leads the overall case management activities and day-to-day operations of the team.
• Assists with the evaluation of policies and workflows identifying potential for efficiencies and provides input to diminish organizational risk and enhance workflows and improvement in process.
• Participates in the design, development, implementation, and maintenance of projects/processes related to D-SNP initiatives that may encompass multiple departments.
• Conducts vendor performance audits and reports D-SNP program performance issues identified
• Collaborates with UM, CM, HEDIS/STARs, and other programs and departments to facilitate optimal program integration and continuity of care.
• May be required to perform utilization management, care management or California Integrated Care Management required duties on a contingent basis should the contracted vendor be unable to perform duties as contracted.
• Prepare reports for review and approval.
• Assists management staff in completing Delegation and Oversight Departmental related projects and goals as assigned.
• Interfaces with other departments in the development, preparation, and distribution of required reports.
• In depth knowledge of Medicare/MediCal Managed Care Plans.
• Performs other job-related duties as assigned.
• Travel independently to conduct delegation oversight with own reliable transportation.
• Adheres to all company policies and procedures relative to employment and job responsibilities.

Employment Standards

• Active, unencumbered California Registered Nursing license, required.
• Required: Associates Degree from an accredited Registered Nursing program.
• 3 year’s minimum experience in Care Management, Utilization Management or related field. Required.
• BSN / MSN degree preferred.
• Professional certification in Care Management, Utilization Management and/or Managed Care preferred.

Knowledge:

• In depth knowledge of utilization management and care management principles.
• Ability to analyze data and identify trends and actionable statistics.
• Knowledge of Medicare/MediCal Managed Care Plans.
• Working knowledge of how to apply evidenced based utilization management criteria.
• Able to manage projects/initiatives to improve program performance.
• Able to communicate positively, professionally, and effectively with others; teach and collaborate with others.
• Effective written and oral communication skills; ability to establish and maintain a constructive relationship with diverse members, management, employees and vendors.
• Able to perform mathematical calculations and calculate simple statistics correctly.
• Able to prioritize multiple tasks; advanced problem-solving; ability to use advanced reasoning to define problems, collect data, establish facts, draw valid conclusions, and design, implement and manage appropriate resolution.
• Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment.
• Comprehend and analyze statistical reports.
• Computer proficiency; Microsoft Office Suite and experience with care management and utilization management software platforms.

Ability to:

Communicate effectively, both verbally and in writing, with internal and external stakeholders; adapt to a rapidly evolving work environment; work independently and manage multi-task responsibilities with a high level of attention to detail; identify challenges and develop strategies to address; prioritize workload; make decisions; prepare and organize data analytics regarding risk adjustment and create an action plan to enhance performance.

Other:

Required travel up to 40%. Possession of valid California Driver’s License and proof of valid State required auto liability insurance.

We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis.

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