Description

California Annual Salary Range: $114,138 - $171,207

Job Summary

 The Enhanced Care Management (ECM) Manager oversees the execution and operations of the ECM program. They act as a subject matter expert (SMEs) and liaisons between CenCal Health and ECM providers, community-based organizations, and providers to promote the effective implementation of ECM’s program goals and objectives. The ECM Manager will perform oversight and support ECM activities that include but are not limited to utilization management, Member assignment, and reporting. The ECM Manager will manage, lead, and mentor the ECM staff. Responsibilities include staying current with regulatory requirements by the state on various ECM aspects and ensuring the health plan remains compliant with the deliverables.

Duties and Responsibilities

• Manage day-to-day operations of the ECM program, including leading cross-functional meetings/teams, ensuring program deliverables are met, and optimizing internal and external ECM processes.

• Develop program policies, standard operating procedures, and program dashboard associated with ECM.

• Provide oversight of ECM providers and delivery of ECM core services to members through reviews of ECM member assessments, care plans, case notes, and related documentation obtained via chart audits, authorizations, and EHR.

• Ensure ECM provider reporting is submitted in a timely and accurate manner. Identify any needed process improvements, develop solutions, and make recommendations for improvement.

• Support the identification of ECM's best clinical and care management practices and promote provider engagement in process improvement efforts.

• Maintain a thorough and up-to-date knowledge of Department of Health Care Services (DHCS) guidance on ECM.

• Participate and serve as a lead during DHCS's audits related to ECM.

• Develop and maintain collaborative relationships with ECM providers within CenCal Health's network.

• Regularly communicate with ECM providers to ensure core service components are delivered to members and to support members in receiving intended ECM services.

• Conduct meetings with potential and contracted ECM providers.

• Ensure that authorization determinations and notifications are completed within prescribed timeframes.

• Guide providers and members regarding timely requests, authorization requirements, etc.

• Monitor staff productivity and compliance.

• Assist with claims review as assigned.

• Measure and report consistency in applying UM criteria (interrater reliability)

• Participate in external or internal meetings and committees related to the ECM.

• Partner with Provider Services in the identification of new providers in order to maintain an adequate ECM provider network.

• Collaborate with Provider Services to develop and implement education/training to ECM providers on core services, reporting, and quality improvement areas.

• Provide clinical support to Health Plan Nurse Coordinators for medically complex cases and participate in clinical rounds as requested.

• Other duties as assigned.

Qualifications

Skills/Knowledge/Abilities

Required:

• Experience building and leading clinical programs.

• Experience leading teams focused on clinical programs and outcomes.

• Demonstrate expertise and ability to function as a case manager.

• Ability to clearly and effectively communicate and collaborate with members and families, physicians, and other health care providers.

• Self-motivated to seek knowledge to improve personal and professional performance.

• Ability to work effectively in a cross-functional team environment.

• Strong computer literacy and skills

• Excellent verbal communication and writing skills are required.

Preferred:

• Knowledge of managed care issues (including benefits and contract limitations, delivery, and reimbursement systems) and the role of medical management activities.

• Knowledge of State and Local social service agencies and community-based organizations.

• Current crisis prevention/intervention certification.

• Knowledge and skills in community-based behavioral health care resources.

• Bilingual (English/Spanish).

Education and Experience

Required:

• A current California RN license and/or Licensed Clinical Social Worker

• Bachelor’s degree.

• Minimum five (5) years of clinical work experience in the above field

• Minimum three (3) years of clinical work experience in a lead or supervisory capacity

• Minimum two (2) years of managed care experience.

Preferred:

• Master’s degree.

• Certified Case Manager.

• Medi-Cal managed care.