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ICTP Supervisor (DC Medicaid)

Company: CareFirst BlueCross BlueShield
Location: Washington
Posted on: September 17, 2020

Job Description:

Resp & Qualifications

POSITION OVERVIEW
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 organization.

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 policies.



PRINCIPAL ACCOUNTABILITIES:
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 Accreditation.
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 plan contracts
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 Management
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.


QUALIFICATION REQUIREMENTS:
Required Education/Experience/Skills/Abilities:
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 programs.

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 situations.
Project Management - Communicates changes and progress; Completes projects o

Keywords: CareFirst BlueCross BlueShield, Washington DC , ICTP Supervisor (DC Medicaid), Accounting, Auditing , Washington, DC

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