Director, Care Management/NP-BC (CA-Remote) Division Coordinated Regional Care Group City Los Angeles Shift Days
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Director, Care Management
– NP-BC (CA-Remote)
We are hospitals and affiliated medical groups, working closely together for the benefit of every person who comes to us for care.
We build comprehensive networks of quality healthcare services that are designed to offer our patients highly coordinated, personalized care and help them live healthier lives.
Through collaboration, we strive to provide all of our patients and medical group members with the quality, affordable healthcare they need and deserve.
Under the direction of the CRC California Medical Director, the Director of Care Management oversees In-Patient and Out-Patient Care Management, Complex and Disease Management, and Complex Care Services Performance Improvement care coordination programs.
Builds/Manages programs, which includes but is not limited to those which support the management of patients with complex and chronic care needs by assessing, developing, implementing, coordinating, monitoring, and evaluating care to prevent re-admissions.
Ensures that Members’ medical, environmental, and psychosocial needs are optimized through the continuum of care.
Director Care Management participates in physician/hospitalist, weekly leadership, operational, department meetings, JOC’s, and MSO daily rounds meetings.
Assists Medical Director with daily operations and oversight of programs and compliance.
Acts as a Liaison and key contact for executive and operational team members and is responsible for communication, coordination and monitoring of organization-wide initiatives and operations related to in/outpatient case management programs.
Is responsible for consistent operational compliance and reporting to satisfy and exceed state, federal and accrediting agency standards.
Under the direction of the Senior Vice President | Chief Operations Officer, assists in budget planning and adherence to the organization’s goals and objectives. Performs other projects and duties as assigned.
Job Responsibilities/Duties
Responsible for interviewing, hiring, and retaining capable staff to execute the organization’s strategic and organizational plans and is responsible for succession planning and the development of identified leaders for advancement within the organization.
Responsible for directing all aspects of comprehensive, quality, cost effective care management for members with complex, serious and chronic medical conditions, focused in the ambulatory and in-patient setting.
Oversight and performance management of these functional areas: Ambulatory Case Management – Complex, and High Intensity; Disease Management Programs; Complex Care Services Performance Improvement Program (CCSPIP); Initial and On-Going Care Planning; Interdisciplinary Team Management.
Ensures that the aforementioned programs are a collaborative process of identification, assessment, planning, intervention, coordination, and evaluation, and as appropriate; integrates the participation of all those involved in the care of the member, including the primary care physician, medical and surgical specialists, nurses, behavioral and mental health specialists, physical, occupational, and speech therapists, social workers, allied health professionals, and community-based providers.
On an ongoing basis assures the following goals are achieved, including, but not limited to: Pro-actively identifying members with serious and complex conditions; Screens and identifies appropriate patients for the CCSPIP; Enhancing the member’s independent living capabilities and maximizing their optimal functioning and management of their chronic conditions; Facilitating the continuity and coordination between providers, facilities, community resources and the health plan; Facilitating interdisciplinary communication, care planning, and member compliance with the physician’s treatment regimen; Enhancing member satisfaction with Prospect’s health care delivery system; Coordinates member’s eligible benefit coverage to best serve their medical conditions and social needs; Through the coordination of cost-effective alternatives, develops an individualized, comprehensive, multidisciplinary care plan that best meets the member’s medical and psychosocial needs.
Collaborates and mentors with team members to develop and meet department and company objectives and strategic goals.
Ensures compliance is maintained with all regulatory reporting assigned to each staff member.
Monitors staff hiring and disciplinary actions with any assigned staff.
Participates in MSO and Hospitalist Daily Rounds and Joint Operation Committees and ensures that Members are being directed to appropriate level of care within network and in those cases where the organization cannot provide the care, that the Member is referred to a contracted provider of care within the network.
Provides consistently positive, constructive interface with internal departments as needed.
Creates structure for the newly developed department, Identifies and develops new policy and procedures, then reviews outcomes that result in process improvement.
Daily Management of Care Management, Disease Management, and CCSPIP Programs.
Daily participation and oversight of Case Management, Daily In-Patient Rounds, MSO In/Out-Patient High Intensity Rounds, Home Visits, Social Workers, Palliative, Hospice and Home Medication Therapy Management Programs.
Interfaces with Medical Director and attends and participates in Interdisciplinary Rounds.
Works collaboratively with Medical Director to ensure compliance is maintained, identifies specialist issues, reviews re-admissions and avoidable admissions.
Coordinates provisions for complex ambulatory care (Disease Management, Social Services, Behavioral Health, Palliative/ Hospice, Health Education, Community Resources, etc.) Compiles and measures performance indicators, trends, and staff activity reports relevant to CCSPIP, case management, disease management and other programs.
Ensures compliance is maintained with all health plan, state, federal, and accrediting agency standards, e.g., CQA/CMS regulations/delegation.
Participates in the development and roll-out of new IPA cohorts to ensure uniformity across all aspects of chronic care management programs.
Collaborates and coordinates care with Hospitalists, MSOs, IPAs, Health Plans, Community Based Programs, Palliative and Hospice Care and Behavioral Health providers as appropriate.
Collaborates with patient’s family and physicians for seamless coordination of care and services.
Monitors and evaluates effectiveness of the chronic and end of life care management plan(s) and modifies as necessary to meet health plans and national standards (i.e., NCQA requirements) for turn-around-time for assessments, care plans and IDTs.
Monitor compliance with achieving set goals and attending scheduled meetings.
Develop Initial Care Plan (ICP) by conditions identified in CCSPIP, patient assessment, medical records authorizations/referrals, primary care physician, member, and Interdisciplinary Team.
Sets patient prioritized self-management goals.
Create cases in the care management platform for each patient under case management with appropriate documentation including but not limited to; cognitive, functional, ADL, environmental factors, psychosocial, medical and benefits etc.
Coordinates care plan and/or assessment findings with health plan care managers, as appropriate.
Utilize available Health Information Systems (HIE) as available to maximize resources, information to help build a plan for each at risk patient.
Manages caseload of chronic and high-risk patients in collaboration with Medical Director and MSO/IPA.
Meets assigned/expected patient contacts daily to assess and coordinate care.
Qualifications
Minimum Experience: A minimum of 5 years of middle to senior management (Manager or Director) experience in Hospital, MSO, Medical Group, IPA or Health Plans to include Care Management, Chronic Care Management, Social Determinants, Utilization Management, Inpatient/Outpatient Case Management Programs, Health Plan Incentive programs to include P4P/HCC.
Experience coaching, growing, and managing staff.
Req.
Certification/Licensure: Active, unrestricted, California licensed Registered Nurse (RN) Required.
Nurse Practitioner training, unrestricted active California NP-C licensure and Board Certification Preferred.
Employee Value Proposition
Prospect Medical Holdings, Inc., is guided by a diverse and highly experienced leadership core.
This group maintains the vision that has made Prospect a needed difference-maker in the lives of so many patients today, and many executives contribute to our continued efforts.
As a member of our highly effective team of professionals, benefit eligible positions will receive:
Company 401K Paid time-off Life insurance
Prospect Medical Systems has a zero-tolerance policy regarding the