Care Management Specialist - Sutter Health PlusJob ID SHP-1825307 Date Posted 12/18/2018 Location Sacramento, California
Under general direction, the Care Management Specialist shall coordinate and provide ongoing organizational support for key care management initiatives, including the interface between clinical team, compliance, legal support, privacy, operations. Facilitates communication between SHP clinical team and Sutter Foundation UM, CM, DM staff and SH subject matter experts. Coordinates and prepares clinical case reviews by evaluating medical information against standardized guideline requirements to determine if additional clinical information is needed. Collects and collates utilization performance data to facilitate the analysis of the efficiency and effectiveness of clinical processes and procedures. Manages SHP UM work plan and prepares reports for established committees. Assists with the development and revision of care management policies and procedures. Performs delegation oversight of delegated entities by organizing audits, monitoring and reviewing submitted reports, performing follow up and reporting compliance to SHP business units. Works with SHP business units to develop and implement corrective action plans as needed.
AA/AS degree or the equivalent combination of education and experience required. BA/BS degree or equivalent combination of education and experience desired.
Must have demonstrated previous experience similar to the required duties. Must have 3-5 years in a managed care or health insurance environment. Experience in coordinator and/or project management positions with exposure to PHI is essential. Must demonstrate knowledge of HIPAA, Health Care Reform, Business Code of Ethics and government regulated programs. Must demonstrate ability to work collaboratively, prioritize functions, problem solve, and anticipate upcoming issues for the executives.
Excellent oral and written communication skills. Excellent telephone skills managing escalated calls. Abilities with Microsoft Word, Excel and PowerPoint, internet research. Must require minimal supervision. Understanding of compliance and quality programs. Knowledge of preventive health standards for adults and pediatrics, NCQA, InterQual, Milliman Care Guidelines, HEDIS, CAHPs. Experience with health plan operations. Must be able to positively interact with clinicians, senior management, members and all levels of clinical and non-clinical professionals in the provider office, medical group, health plan and regulatory agencies.
Employee Status: Regular
Position Status: Non-Exempt
Job Shift: Day
Shift Hours: 8 Hour Shift
Days of the Week Scheduled: Monday-Friday
Weekend Requirements: None
Schedule: Full Time
Hrs Per 2wk Pay Period: 80
All qualified applicants will receive consideration for employment without regard to race, color, creed, religion, marital status, sexual orientation, registered domestic partner status, sex, gender, gender identity, or expression, ancestry, national origin, age, medical condition, physical or mental disability, military or protected veteran status, political affiliation, pregnancy, childbirth or related medical condition, genetic information or any other characteristic made unlawful by local, state, or federal law, ordinance or regulation. External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with Federal, state, and local laws, including but not limited to the San Francisco Fair Chance Ordinance.