Care Management Supervisor

MCS Puerto Rico; San Juan (PR); On-site; USD 70,000 - 90,000; Full time

Benefits offered by this job

Restaurant d'entreprise

Job summary

MCS Puerto Rico seeks a Nurse Care Management Supervisor to lead the Care Management Program work plan across our lines of business in Puerto Rico. You will ensure resources, compliance with guidelines, and the development of evidence‑based care management protocols.

This role supervises staff, coordinates referrals for medical, psychosocial, and educational needs, and prepares regulatory reports. A Puerto Rico nursing license and at least three years of clinical program supervision are required.

Qualifications

• Bachelor's degree in Nursing Science required.
• At least 3 years in clinical programs or medical treatment roles.
• Must possess a valid Puerto Rico nursing license.

Responsibilities

• Manage Care Management Program work plan across the different MCS business lines.
• Prepare, review, revise, and maintain updated operational guidelines for Care Management.
• Develop and implement Care Management Policies and Procedures.
• Oversee care management interventions and ensure processes meet regulatory standards.
• Monitor staff activities and coordinate educational/training resources.
• Coordinate referrals to address medical, psychosocial, and educational needs.
• Submit required regulatory reports and ensure external service coordination.
• Lead interdisciplinary case discussions with Providers and Medical Directors.
• Monitor monthly statistics and communicate barriers to program goals.
• Supervise and train personnel to comply with policies and procedures.

Skills

Supervision

Care management

Interdisciplinary collaboration

Regulatory compliance

Education

Bachelor's degree in Nursing Science

Job description

GENERAL DESCRIPTION

Manages and ensures the effective execution of the Care Management Program work plan for the Company's lines of business. Ensures that the appropriate resources are in place to ensure compliance with the appropriate care management of the participating members of the program(s). Participates in designing, developing, and updating the Care Management Guidelines based on acceptable medical and scientific evidence. Evaluates care management interventions performed by staff under their charge to policyholders identified by the Care Management program, according to procedures established by MCS and regulatory agencies. Serves as clinical support in consultations requested by other departments and designs protocols for care management interventions.

Regular Exempt

GENERAL DESCRIPTION

Manages and ensures the effective execution of the Care Management Program work plan for the Company's lines of business. Ensures that the appropriate resources are in place to ensure compliance with the appropriate care management of the participating members of the program(s). Participates in designing, developing, and updating the Care Management Guidelines based on acceptable medical and scientific evidence. Evaluates care management interventions performed by staff under their charge to policyholders identified by the Care Management program, according to procedures established by MCS and regulatory agencies. Serves as clinical support in consultations requested by other departments and designs protocols for care management interventions.

ESSENTIAL FUNCTIONS

• Manages, monitors, and ensures compliance with the Care Management Program work plan for the different MCS business lines.
• Prepares, reviews, revises, and maintains updated Care Management Program operational guidelines as needed.
• Participates in and facilitates creating, developing, updating, and implementing Care Management Program Policies and Procedures.
• Oversee documents, evaluates, assesses, analyzes, and monitors care management interventions performed by staff under their charge to the policyholders participating in the program. Ensures that they are performed following procedures established by MCS and regulatory agencies, including but not limited to the Model of Care and Care Management Program Description.
• Monitors the daily activities of the Care Management Program staff and ensures coordination of educational and training activities with internal or external resources to achieve and maintain effective and efficient operation of the program.
• Coordinates the referrals received from other departments and/or units to manage and meet the mental health, physical, functional, psychosocial, and/or educational needs of identified policyholders.
• Submits the reports required by the regulatory agencies, according to the established itinerary or as requested.
• Ensures coordination for the provision of services from outside carriers to identified policyholders.
• Actively participates as a clinical resource in interdisciplinary interventions delivered to the policyholders participating in the program, including but not limited to policyholders with chronic and/or fragile conditions through the Interdisciplinary Complex Team (IDCT Complex).
• Develops, monitors, analyzes, and maintains measurement mechanisms/tools/indicators and outcomes (production of utilization, operational and cost efficiency metrics) to document and analyze the program's effectiveness and its care management interventions offered to the participating policyholders.
• Leads case discussions with Providers, Medical Directors, Care Management Managers, Care Management Director, and/or any other MCS department as needed for case management and validation of chronic condition criteria and/or utilization.
• Monitors, analyzes, and maintains monthly statistics of the efforts/activities performed by the Care Management Specialists under their charge.
• Identifies, documents, and communicates situations/barriers to achieving the program's goals and/or effectiveness indicators and finding solutions.
• Participates in and facilitates the development and implementation of improvement plans based on monitoring and analyzing the program effectiveness results.
• Supervises, monitors, trains, evaluates, and corrects personnel among others to comply with his/her role as a supervisor, to assure that his/her personnel fulfill their work plan and comply with their essential functions and that they behave following the policies, standards, norms, and procedures of the Company.
• Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices.
• May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document.

MINIMUM QUALIFICATIONS

Education and Experience

Bachelor's degree in Nursing Science. At least three (3) years of experience in clinical programs, medical treatment, or service authorization processes, in a healthcare environment, which includes at least one (1) year in a supervision position. Certifications / Licenses: A valid Nurse & Association Nursing Professionals of Puerto Rico license and registration are required.

Other

N/A

Languages

Spanish – Advanced (comprehensive, writing and verbal)

English – Advanced (comprehensive, writing and verbal)

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