ICTP Supervisor (DC Medicaid)
Company: CareFirst BlueCross BlueShield
Posted on: September 17, 2020
Resp & Qualifications
The Supervisor supports the Director of Healthy Families Case
Management and the CareFirst Mission of providing affordable health
insurance and accessible health care to all. The Integrated Nurse
Care Supervisor will collaborate with Utilization Management, Case
Management and Provider Relations to improve the conditions which
have led to chronic ED utilization, hospital readmissions and
inpatient behavioral health admissions. The Supervisor will adhere
to the principle of the Quadruple Aim improving enrollee
experience, better outcomes, improved clinical experience, lower
costs while pursuing health equities for our enrollees. The
supervisor builds an effective, efficient workforce to support all
aspects of the Case Management department across the continuum of
care settings and clinical programs and services for enrollees.
Depending on the specific business area, the Supervisor may oversee
the work of non-clinical staff including Care Coordinators and
Community Health Worker. The role works closely with the Chief
Medical Officer, Director of Case Management, Program Manager and
Business Analyst and case management to develop and operationalize
sustainable processes to support functional improvements for the
ESSENTIAL DUTIES AND RESPONSIBILITIES
The Integrated Nurse Care Supervisor will explain care options to
patients and their families and coordinate with healthcare facility
staff to ensure that each patient has a smooth transition through
the discharge process to their discharge destination.
Responsible for managing day to day operations for the Integrated
Care Team including completion of HRA screens.
Analyze data to measure individual team performance.
Completes annual performance evaluations of direct reports.
Completes payroll in People Soft for direct reports.
Collaborates with members and their medical/health and
community-based providers (including the PCP, certified dieticians,
behavioral health specialists, or others as needed) regarding the
member s treatment needs and plan of care.
Attends weekly medical management operations meeting and provides
status reports on discharge plans and other ad-hoc reports.
Collaborates with Utilization Management to ensure timely
processing of prior authorization requests.
Adheres to quality assurance standards in all medical management
Under the general direction of the Director, the Manager s
accountabilities include, but are not limited to, the following
(specific goals for Case Management Department are determined on an
annual basis in accordance with directives from the executive board
of CareFirst Community Health Plan Blue Cross Blue Shield):
1. SUPERVISE CASE MANAGEMENT PROCESS
Identification/Risk Stratification:) Engages enrollees into the
case management program (outreach and successful enrollment) using
diagnostic cost grouper classification reports, which identify the
relative risk score and illness burden. Identifying catastrophic
health care users with significant health care costs in the High
Intensity care needs.
Assessment: Conducts and documents a comprehensive assessment of
the enrollee s health psych/social needs, including health literacy
and deficits. Obtains verbal consent to initiate case management
services. Gathers clinical, which includes past medical history,
medications, physical/psychosocial factors, cultural influences,
evaluation of health care barriers to include available support
systems, available benefits, community resources, and treatment and
medication compliance according to NCQA Case Management
Planning: Proficient case management clinical knowledge and
experience to coordinate integrated care-plan development involving
the enrollee, family, Care Coordination (CC) and Care Manager
(RNCM), Primary Care Physician (PCP), specialists and other
healthcare providers/vendors. Goals developed will be prioritized,
action-oriented and time-specific to stabilize the complicated
health care condition and meet NCQA standards of documentation for
Case Management Accreditation
Facilitation of Communication and Care Coordination: Executing the
transition of care includes moving the enrollee from one healthcare
practitioner and setting to another as their healthcare needs
change. One key responsibility of the supervisor is to minimize the
fragmentation of care services and adverse outcomes. Completes a
review of service request containing all appropriate information
(clinical, medical policy, contact/complex benefit structure, FDA
treatment, clinical trials and drugs) to allow the medical director
to make a medical necessity determination. Identifies and provide
educational and community resources, support groups, pharmacy
program and financial assistance.
Monitoring: Documentation will reflect the necessary communication
with the enrollee, family, physicians, and other health care
providers to ensure the enrollee s progression in meeting the
established care plan goals.
Outcomes Management: Evaluate the extent to which the established
goals in the plan of care have been achieved.
2. MONITOR APPLICATION PROFICIENCY AND ASSIST WITH ISSUES
Portal Data Base: Case management documentation is completed in the
Care Connect system
Claims: Assists in claims inquiries and resolution
Legacy Systems (MHC, Care Connect and OSSE): Confirms enrollee
eligibility and available benefits
Care Planner Web: Authorization management; generates coverage and
adverse decision correspondence using appropriate language to meet
state, federal and all regulatory requirements
Employer Group/Accreditation Audits: Participates in the
preparation and on-site reviews (NCQA, OSR and DHCF)
Knowledgeable of federal/state mandates as they apply to various
Documentation Audit: Responsible for completion of documentation
review and peer to peer audit as assigned by management
MCG Chronic Care Guidelines: Familiarity with and usage of for the
purpose of discharge planning (and length of stay review for FEP
Line of Business only)
NCQA Compliance: Responsible for adherence to the NCQA Complex Case
Management Standards and Health Plan Standards
CMSA: Adheres to the CMSA Standards of Practice for Case
HIPAA: Maintains confidentiality of patient information according
to HIPAA and departmental policies.
3. OTHER DUTIES AS ASSIGNED
Approve day to day operations such as payroll, performance reviews,
attendance and time off
Supervise Case management referrals, ombudsman complaints and
requests to speak to a supervisor
Monitor and approve the compiling monthly and ad hoc reporting to
District Health Care Finance
This position is expected to attend meetings in support for the
Director of Case Management as needed.
Registered Nurse in the District of Columbia in good standing
Bachelor s Degree in Nursing preferred
Certified Case Management Certification preferred and must be
obtained within 2 years from hire date
Three to Five Years of experience in management in homecare,
hospice, or managed care
Note: The supervisor is required to immediately disclose any
debarment, exclusion, or other event that makes him/her ineligible
to perform work directly or indirectly on Federal health care
To perform the job successfully, an individual should demonstrate
the following competencies:
Analytical - Experience working with statistical methodologies,
analytical and statistical theories. Knowledge of applied use of
data in health program monitoring and evaluation.
Problem Solving - Identifies and resolves problems in a timely
manner; Gathers and analyzes information skillfully; Develops
alternative solutions; Works well in group problem solving
Project Management - Communicates changes and progress; Completes
Keywords: CareFirst BlueCross BlueShield, Washington DC , ICTP Supervisor (DC Medicaid), Accounting, Auditing , Washington, DC
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