OVERVIEW OF THE POSITION:
Oversees the ACO Unit staff directly responsible for the day-to-day operations of care management programs. Responsible for the supervision and optimization of ACO quality improvement, utilization management and care management activities as it relates to ambulatory case management, social services, home health, health education and other health care delivery programs within Health Care Partners Medical Group. Works with all members of the ACO Team, as well as department leads for Health Enhancement, Quality Improvement and Regional Case Management, to facilitate optimal integration of ACO patients into Health Care Partners standard operating procedures and programs. Contributes to the clinical, quality, financial and patient satisfaction outcomes of the ACO department.
Establishes familiarity with ACO lines of business and demonstrates understanding of goals and key performance indicators for both the organization and our ACO plan partners.
Oversees day to day operations and efficiency of Unit staff and clinical programs. Escalates issues to Director, makes recommendations for programmatic development and changes per assessment.
Identifies need for and participates in the development and implementation of care management and utilization management policies and procedures, and ensures compliance throughout the Unit.
Provides supervision and guidance to ACO Case Managers and Care Coordinators ("ACO Unit")
Responsible for monitoring ACO Unit productivity and providing coaching and corrective action as indicated.
Responsible for tracking patient referral and engagement volumes by line of business and program type, and reporting out each month to leadership team.
Evaluates staffing and CM Unit workflows to support changing ACO clinical and business goals, and collaborates with ACO leadership to determine/ implement process and workflow changes.
Provides input on ACO teammate relations, hiring, termination, professional development and performance development based on role expectations and clinical assessment of skills needed.
Ensures that staff has the information, tools and training necessary to perform their functions accurately and efficiently.
Utilizes health plan and internal risk stratification reporting to identify high risk/high utilizer patients for ACO Unit outreach. Reviews available reporting to identify trends in patient, facility and provider utilization and quality. Makes recommendations to leadership regarding interventions to improve all resource management.
Participates in health plan JOCs, Board meetings and Operational/Clinical meetings as appropriate.
Conducts monthly ACO Team meetings including utilization management review, productivity audits, outcome measurements and identification of training/educational opportunities.
Identifies, develops and oversees the educational needs of ACO care management staff, providers and others. These include an extensive orientation program, cross-training and proactive approach to case management.
Identifies opportunities for the development of new care management approaches that support department, organizational and health plan goals.
Collaborates directly with health plan liaisons to streamline medical group and health plan resources for ACO patients.
Uses, protects, and discloses HCP patients' protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards.
Performs additional duties as assigned.
Bachelor's degree from a four-year college and/or a professional certification requiring formal education beyond a two-year college.
Graduate of an accredited school of Nursing.
Current California RN license.
Basic Life Support for Providers (AHA) -100% online certification is not acceptable.
Advanced Life Support and or PALS certification preferred.
Specialty certifications in OR, OB, GI, ER, CEN or CCRN as needed
I.V. therapy certification
1 or 2 years of post-high school education or a degree from a two-year college.
Graduate from an accredited school of Nursing.
Current California RN license.
Over 3 years and up to and including 5 years of healthcare experience.
Over 1 year supervisory/management experience, preferably in a medical group / IPA or HMO setting.
KNOWLEDGE, SKILLS, ABILITIES:
Proficient in Microsoft Office applications (Word, Excel, Access).
Strong organizational skills.
Excellent verbal and written communication skills.
Strong analytical and problem-solving skills with ability to make sound and independent judgments