Manager, CM (RN)

RN license for state of California required.

Position Purpose: Manages the care management team and the care management of members to develop and assess high quality, cost-effective healthcare outcomes. Manages escalations and care management issues related to members or providers.

• Oversees and reviews care management required documentation to maintain compliance with federal and state regulations and contractual agreements
• Contributes to the development and implementation of policies and procedures within the care management team based on regulatory requirements and industry standards
• May direct the daily activities of care management staff including reviewing and approving the caseloads based on state requirements, care management staff experience, and member needs
• Manages processes for escalation and/or complex cases, and provides guidance to team members to address member needs
• May manage or coordinate resolutions of member escalations and/or complaints and assists in audits and evaluations related to care programs and member concerns
• Contributes to the development, implementation, and oversight of care management programs to facilitate the use of appropriate services and resources
• May perform telephonic, digital, home and/or other site outreach to assess member needs and collaborate with resources
• Sets goals and objectives for care management team and oversees care management data and reporting metrics to achieve quality and cost-effective healthcare results and works with senior leadership, as required
• Monitors audits within care management to ensure compliance with regulatory requirements for federal, state, and National Committee for Quality Assurance (NCQA) standards, as required
• Provides feedback to care management team to improve member and provider experience and high-quality care
• Educates and provides resources for care management team on key initiatives and member outreach to facilitate on-going communication between care management team, members, and providers
• Assists care management senior leadership with onboarding, hiring, and training care management team members
• Leads and champions change within scope of responsibility
• Performs other duties as assigned
• Complies with all policies and standards

Education/Experience: Requires Graduate from an Accredited School or Nursing or a Bachelor's degree and 5+ years of related experience. *Prefer UM and CM experience.

License/Certification

• RN - Registered Nurse - State Licensure and/or Compact State Licensure required

*Must be licensed in California.

Location: Position is remote. Will work PST hours.

Pay Range: $102,900.00 - $190,500.00 per year