Manages the care management team that serves long-term care members with physical/medical health needs and/or behavioral/mental health needs to develop and assess high quality, cost-effective healthcare outcomes. Manages escalations and care management issues related to members or providers. Oversees and reviews long-term care management required documentation to maintain compliance with federal and state regulations and contractual agreements. Develops, implements, and oversees long-term care m... more details
You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you’ll have access to competitive benefits including a fresh perspective on workplace flexibility.
Hybrid - 1 day a week in the 700 Prides Crossing, Newark DE office, and as needed.
Position Purpose: Manages the care management team that serves long-term care members with physical/medical health needs and/or behavioral/mental health needs to develop and assess high quality, cost-effective healthcare outcomes. Manages escalations and care management issues related to members or providers.
- Oversees and reviews long-term care management required documentation to maintain compliance with federal and state regulations and contractual agreements
- Develops, implements, and oversees long-term care management policies and procedures within the long-term care management team based on regulatory requirements and industry standards
- Assigns, monitors and evaluates work assignments and caseloads of long-term care management staff based on state requirements, care management staff experience, and member needs
- Directs the daily activities of long-term care management staff including reviewing and approving the caseloads based on state requirements, care management staff experience, and member needs
- Manages escalated and complex care cases, and provides guidance to long-term care team members to address member concerns related to physical/medical health and/or mental/behavioral health needs
- May perform telephonic, digital, home and/or other site outreach to assess member needs and collaborate with resources
- Ensures proper coordination and communication of medical service functions with other departmental functions at the business as assigned
- Develops, implements, and oversees long-term care management programs to facilitate the use of appropriate services and resources
- Sets goals and objectives for long-term care management team to achieve cost-effective healthcare results
- Monitors audits within care management to ensure compliance with regulatory requirements for federal, state, and National Committee for Quality Assurance (NCQA) standards, as required
- Works with long-term care management senior management to provide updates and insights on care management team goals
- Reviews long-term care member data to identify trends and improve operating performance and quality care in accordance with state and federal regulations
- Provides coaching and guidance to long-term care management team to improve member and provider experience and facilitate delivery of high-quality care
- Educates and provides resources for long-term care management team on key initiatives and member outreach to facilitate on-going communication between care management team, members, and providers
- Assists long-term care management senior leadership with onboarding, hiring, and training long-term care management team members
- Leads and champions change within scope of responsibility
- Performs other duties as assigned
- Complies with all policies and standards
Education/Experience: Positions overseeing RN team members: Requires Graduate from an Accredited School or Nursing or a Bachelor's degree and 5+ years of related experience. Or,
Positions overseeing BH team members: Requires a Master's degree or Graduate from an Accredited School of Nursing and 5+ years of related experience.
Or equivalent experience acquired through accomplishments of applicable knowledge, duties, scope and skill reflective of the level of this position.
2+ years supervisory experience, preferred.
Highly advanced clinical knowledge and ability to assess member needs in context of relevant diagnoses, treatment plans and goals, and identify potential gaps in care or risks for readmission or complications preferred.
Strong knowledge of healthcare managed care principles preferred.
Experience working with providers and healthcare teams to develop appropriate long-term service plans/care plans preferred.
Strong knowledge of medication indications and side effects and/or knowledge of BH care management principles preferred preferred.
License/Certification:- Positions overseeing RN team members: Current state's Registered Nurse (RN) license Upon Hire required or
- Positions overseeing BH team members: Licensed Clinical Behavioral Health Professional or RN based on state contract requirements e.g., LCSW, LMSW, LMFT, LMHC, and RN with BH experience required Upon Hire required
- For Superior: Must be RUG certified if oversee RN team members
Pay Range: $98,900.00 - $183,100.00 per year
Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law. Total compensation may also include additional forms of incentives.
Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.
