Health Services Manager
Reports to: VP, Global Health Services
Department: Global Health Services
Calibrated Healthcare Network (CHN) manages over 11 million lives in over 8 states, partnering with industry leaders in the area of managed care. Our operating model features global workforce strategies, coupled with efficient technological solutions. We have a proven expertise in re-engineering complex managed care business processes to provide value to our esteemed partners. Our commitment to the evolution of healthcare is evident in our investment in research and development for the progression of dynamically enhanced technology to meet the needs of partners. The core suite of services includes Claims Adjudication, Benefits Setup, Member Enrollment and Eligibility Setup, Claims System Configuration, HCC Coding and MSO Development support.
The Calibrated Clinical Solution (CCS) global workplace is built on the concept of providing cost-effective care, enhancing population health strategies, and improving the quality of care. Calibrated Clinical Solutions deploys the use of proprietary software to create cost-effective workforce solutions constructed on the premise of collaboration technology. With our extensive domain of knowledge of managed care and dynamically enhanced technology, we have the capacity to create innovative solutions for our managed care and primary practice partners. Our core suite of services includes Medical Management, Utilization Management, Complex Case Management, and Population Health Management.
Under the direction of the VP, the role is responsible for leadership and management of the day to day operations of the Health Service division to ensure all activities adhere to NCQA, DHCS, DMHC, CMS, and State regulatory standards. The Manager is accountable for ensuring the strategic direction aligns with departmental key objectives and operates in accordance with Calibrates mission, vision, and values. This role is integral in ensuring quality performance in Population Health Management, Case Management, Utilization Management, and other Programs/Projects, as assigned.
- Bachelor of Science in Nursing required
- Masters Degree preferred
- A current active Registered Nurse license issued by the California Board of Registered Nursing.
- Certified Case Manager (CCM) preferred
- Accredited Case Manager (ACM) preferred
- Certified Managed Care Nurse (CMCN) preferred
- Six Sigma certification preferred
- Minimum 2 years clinical practice experience required, preferably in an acute care setting.
- Previous case management and/or utilization management experience required
- 3-years managed care experience preferred
- Demonstrated Leadership Competencies: Business Acumen, Command Skills, Conflict Management, Customer Focus, Ethics and Values, Timely Decision-Making, Process Management, Drive for Results, Building Effective Teams, Functional and Technical Skills
- Strong written and verbal communication skills, strong analytical skills
- Demonstrated ability to work together across professions and individuals to improve health outcomes
- Computer Proficiency (MS Word, MS Excel, MS Outlook, Video Conferencing)
- Capacity to interpret evidenced based guidelines, health plan/client specific chronic care guidelines, and policies/procedures
- Knowledge of NCQA, DMHC, and state requirements for case management
- Knowledge of core Utilization Management and Care Management processes and the ability to ability to mobilize resources to carry out operational objectives.
Essential Functions of Job
- Able to perform the essential functions of the clinical staff reporting to the position and assist with workload when required.
- Facilitates the general execution of each service line of the Healthcare services division; including, but not limited to, population health management, ambulatory case management, complex case management, utilization management, transition of care management, and inpatient reviews.
- Responsible for the identification of opportunities for improvement and appropriate management of performance improvement activities for direct reports.
- Responsible for appropriate resource use, staffing, cost containment, and regional program development based on regulatory requirements.
- Responsible for contract compliance through the data collection and analysis of client-based performance measures and facilitating the appropriate action strategies or corrective action plans.
- Responsible for accreditation compliance management.
- Assist in the hiring, training, coaching and counseling of direct reports.
- Responsible for the introductory and annual performance evaluations of direct reports.
- Effectively communicates with external and internal customers.
- Responsible for consistent interface with senior management to provide visibility on local operations.
- Responsible for attaining a comprehensive knowledge of client-based platforms and creating Desktop procedures.
- Responsible for remaining current on industry changes and assisting in the development of Policies and Procedures and implementation changes.
- Any other duties as required