Peak Care Manager

WVU Medicine; Morgantown (WV); Hybrid; USD 70,000 - 95,000; Full time

Job summary

WVU Medicine in Morgantown, WV is seeking a Care Manager to join the medical management team. This role identifies high-risk members and connects them with appropriate resources to improve outcomes.

You will triage self-referrals, perform health data reviews, and coordinate with in-network providers while adhering to NCQA standards and program guidelines.

The position requires an RN license and at least 3 years of clinical healthcare experience; BSN/ASN is preferred with ongoing BSN progression.

Qualifications

• Current RN license valid in the state or multi-state eNLC license.
• Minimum of 3 years healthcare clinical experience.
• Preferred: BSN or ASN with BSN completion within 3 years; Medicare/Medicaid care management experience.

Responsibilities

• Participate in activities related to care management program build, implementation, oversight, and delegation.
• Perform utilization management reviews according to criteria and policies.
• Manage and triage member self-referrals to care management programs.
• Assist members in understanding their medical benefits and connecting with in-network providers and resources.
• Identify barriers preventing the member from achieving quality of life.
• Review HRA data to drive development of programs and services.
• Review member outcomes data and support performance improvement opportunities.
• Audit processes using NCQA standards.
• Investigate potential quality of care issues affecting member health.
• Review/update activities and resources to address member needs.

Skills

InterQual/Milliman guidelines

NCQA regulations

Communication skills

Problem solving

Attention to detail

Microsoft Office

Education

RN license

BSN or ASN preferred

Tools

Microsoft Office

Job description

Welcome! We’re excited you’re considering an opportunity with us! Below, you’ll find other important information about this position.

Reporting to Manager of Care Management, the Care Manager will be an integral member of the health plan’s medical management team. This position is responsible for identifying and connecting high risk members to appropriate resources and programs to achieve optimal quality and financial outcomes.

Responsibilities include managing and triaging self-referrals, identifying high risk members through HRA, reporting and admissions data, auditing patient charts of delegated case management programs to meet accreditation standards, and connecting members with in-network providers and resources. This position is committed to the constant pursuit of excellence in improving the health status of the community.

MINIMUM QUALIFICATIONS

1. Current Registered Nurse license issued by the state in which services will be provided or current multi-state Registered Nurse license through the enhanced Nurse Licensure Compact (eNLC).
2. Three (3) years of healthcare clinical experience.

PREFERRED QUALIFICATIONS

1. Bachelor's Degree in Nursing OR Associate of Science in Nursing Degree (ASN); Currently enrolled in a BSN program and BSN completion within three (3) years of hire.
2. Management of Medicare and/or Medicaid populations.
3. Two (2) years Care Management experience.

CORE DUTIES AND RESPONSIBILITIES

The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.

1. Participate in activities related to care management program build, implementation, oversight, and delegation.
2. Perform utilization management reviews as needed according to accepted and established criteria, as well as other clinical guidelines and policies.
3. Manage and triage member self-referrals to care management programs.
4. Assist members in understanding their available medical benefits and connecting them with in network providers and community resources.
5. Identify barriers preventing the member from meeting maximum quality of life.
6. Review and Evaluate Health Risk Assessment (HRA) data to help drive development of programs and services geared toward member needs.
7. Review and Evaluate member outcomes data and work with other team members on performance improvement opportunities.
8. Utilizing NCQA standards in auditing processes of member records as part of care management oversight processes.
9. Investigating potential quality of care issues that may affect the quality or safety of the health of members.
10. May review medical records and other documentation to ensure quality care.
11. Assist in reviewing and updating activities and resources to address member needs.
12. Participate in case management and quality committees.
13. Assist in reviewing and updating policies and procedures to align with delegated processes.
14. Assist in quarterly reporting of delegated case management processes to meet accreditation standards.
15. Assist in submission of required documents/policies during application process to accrediting body.

WORKING ENVIRONMENT

1. Standard office environment

SKILLS AND ABILITIES

1. Working Knowledge of InterQual and/or Milliman Care Guidelines
2. Demonstrated knowledge of federal and state laws, NCQA and industry regulations related to disease management, utilization management, care management and discharge planning
3. Excellent written and oral communication
4. Problem solving capabilities to drive improved efficiencies and customer satisfaction
5. Attention to detail
6. Proficiency with Microsoft Office

Additional Job Description

HYBRID (will be on-site Morgantown, WV) Scheduled Weekly Hours: 40 Shift: Exempt/Non-Exempt: United States of America (Exempt) Company: PHH Peak Health Holdings Cost Center: 2403 PHH Medical Management Address: 1085 Van Voorhis Rd Morgantown West Virginia

Equal Opportunity Employer West Virginia University Health System and its subsidiaries (collectively "WVUHS") is an equal opportunity employer and complies with all applicable federal, state, and local fair employment practices laws.

WVUHS strictly prohibits and does not tolerate discrimination against employees, applicants, or any other covered persons because of race, color, religion, creed, national origin or ancestry, ethnicity, sex (including gender, pregnancy, sexual orientation, and gender identity), age, physical or mental disability, citizenship, past, current, or prospective service in the uniformed services, genetic information, or any other characteristic protected under applicable federal, state, or local law. All WVUHS employees, other workers, and representatives are prohibited from engaging in unlawful discrimination. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, training, promotion, discipline, compensation, benefits, and termination of employment.

The West Virginia University Health System is West Virginia’s largest health system and largest private employer, providing care to communities across West Virginia, Maryland, Ohio, and Pennsylvania. The integrated academic health system includes 25 hospitals and five institutes, with more than 3,500 licensed beds, 4,000 clinicians, 39,000 employees, and $8.5 billion in annual operating revenues. Anchoring the system in Morgantown, West Virginia, are WVU Hospitals, an 880-bed academic medical center, and the 150-bed WVU Medicine Golisano Children’s Hospital. Together, the Health System’s hospitals, clinics, and specialty programs provide a comprehensive continuum of care, ranging from community-based primary and specialty services to highly complex, quaternary care and post-acute care.