Manager – Care Coordination & Utilization Management

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Job Description:

• The Manager, Care Coordination and Utilization Management is responsible for the operations of the continuum of care management, including both care coordination and utilization management. This position is responsible for leading the development, implementation, and evaluation of care management health initiatives aimed at improving health outcomes and reducing healthcare costs for defined populations. This role requires a strategic thinker with a deep understanding of population health principles, utilization management, healthcare delivery systems, and data-driven decision-making.

  Essential Functions:

  • Manages day-to-day operations of the department and employees, recognized problems, and systematically gathers information to help solve problems and improve employee satisfaction

  • Leads a team of nurses, social workers, and non-clinical staff, including addressing performance problems decisively and objectively, provides guidance and assistance to improve performance, rewards hard work and risk-taking, motivates, challenges, develops employees, and delegates effectively.

  • Uses resources efficiently, always looking for ways to reduce costs, creates accurate and realistic budgets, tracks and adjusts budgets, and contributes to budget planning

  • Works cross-departmentally with PHP, Alpine Associates, and new markets to provide leadership and direction on program design, implementation, and evaluation, including traveling and interacting with local markets.

  • Aligns and oversees care management activities to support success with organizational key objectives

  • Provides analysis and utilizes program data to include making suggestions for and implementing clinical process changes, improvements, program design and implementation of new initiatives and programs.

  • Conduct audits and assessments of healthcare services provided to delegated populations, ensuring compliance with regulatory requirements, contractual agreements, and quality standards.

  • Monitor delegated entities’ adherence to regulatory requirements, accreditation standards, and contractual provisions through ongoing audits, reviews, and follow-up activities.

  • Facilitate communication among with primary care providers both virtually and in-person across all markets to promote positive patient outcomes and continuity of care.

  • Participates in and represents Care Coordination in workgroups such as monthly JOC’s, client-based meetings, and other internal and external committees. 

  • Adheres to the company’s Compliance Program and to federal and state laws and regulations

  • Other duties as assigned

  Only for job posting

  This position is a full-time, hybrid role, who is also be expected to meet with community members.  

  Knowledge, Skills and Abilities:

  • Knowledge of people management including mentoring, motivation, and conflict resolution

  • Excellent project management and organizational skills

  • Ability to sort through complex issues, make appropriate, timely decisions, and communicate decisions to others

  • Knowledge of other roles and perspectives

  • Excellent written and oral communication skills

  • Exceptional presentation skills

  • Familiarity with care coordination models, principles, and best practices aimed at improving care transitions, enhancing patient outcomes, and reducing healthcare costs.

  • Understanding of healthcare delivery systems, including hospitals, clinics, long-term care facilities, and community-based services.

  • Ability to leverage data analytics tools to identify trends, track outcomes, and optimize care delivery

  • Ability to provide culturally competent care and tailor interventions to meet the unique needs of diverse populations.

  Qualifications:

  • Education requirements

  • Graduate of accredited school of nursing as an RN.

  • 3- 5 years’ clinical experience as RN.

  • Extensive experience with utilization review

  • 3- 5 years’ experience in management of healthcare related staff

  • 3-5 years’ experience supervising professional staff

  • 3- 5 years’ experience in program design, implementation, and evaluation

  • Experience with commercial health insurance plans preferred

  • Knowledge of NCQA, QA, Medicare/Medicaid guidelines, program and workflow development, process improvement and implementation procedures, care coordination, especially care transitions models and health coaching models

  • Skilled in exercising a high degree of initiative to achieve organizational objectives

  • Skilled in teaching others and acting as a subject matter expert, motivational Interviewing, judgment and decision-making, customer service by being able to relate well to all kinds of people inside and outside the organization, builds appropriate rapport, uses diplomacy and tact, can diffuse even high-tension situations comfortably

  • Able to perform intermediate level of competence with various computer software applications including MS Outlook, Word, Excel, Access, and Power Point

  • Home office that is HIPAA compliant for all remote or telecommuting positions as outlined by the company policies and procedures

#Indeed

Salary Range:

$90,016 - $112,519