Peak Care Manager

Peak Health; Weston (WV); On-site; USD 65,000 - 90,000; Full time

Job summary

PHH Peak Health Holdings in the United States is seeking a Care Manager to support the health plan’s medical management team. You will identify high-risk members, triage referrals, and connect patients with in-network providers and resources to improve health outcomes and quality of life.

The role requires a current RN license, 3 years of clinical experience, and knowledge of care management guidelines. You will work in a standard office environment and collaborate across teams to ensure

Qualifications

• Current RN license in the state where services will be provided or multi-state license through eNLC.
• Three (3) years of healthcare clinical experience.

Responsibilities

• Participate in care management program build, implementation, oversight, and delegation.
• Perform utilization management reviews per established criteria and policies.
• Manage and triage member self-referrals to care management programs.
• Assist members in understanding medical benefits and connecting with in-network providers.
• Identify barriers preventing the member from achieving quality of life goals.
• Review Health Risk Assessment (HRA) data to drive program development.
• Review member outcomes data and contribute to performance improvement.
• Audit member records per NCQA standards as part of oversight.
• Investigate potential quality of care issues.
• Review and update activities and resources to address member needs.
• Participate in case management and quality committees.
• Assist in policy updates to align with delegated processes.
• Assist in quarterly reporting of delegated case management.

Skills

Guidelines knowledge InterQual/Millim

Regulatory knowledge NCQA

Communication skills (written & verbal

Problem solving

Attention to detail

Microsoft Office proficiency

Education

RN license (state or multi-state via eNLC)

ASN or BSN candidate

Tools

Microsoft Office

Job description

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 connect 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

EDUCATION, CERTIFICATION, AND/OR LICENSURE

• 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).

EXPERIENCE

• Three (3) years of healthcare clinical experience.

PREFERRED QUALIFICATIONS

EDUCATION, CERTIFICATION, AND/OR LICENSURE

• 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.

EXPERIENCE

• Management of Medicare and/or Medicaid populations.
• Two (2) years Care Management experience.

CORE DUTIES AND RESPONSIBILITIES

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

WORKING ENVIRONMENT

• Standard office environment

SKILLS AND ABILITIES

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

Additional Job Description

Scheduled Weekly Hours: 40

Exempt/Non-Exempt: United States of America (Exempt)

Shift: United States of America (Exempt)

Company: PHH Peak Health Holdings

Cost Center: 2403 PHH Medical Management