Position Purpose
Directs the long-term care of members with physical/medical health needs and/or behavioral/mental health needs to develop and assess high quality, cost-effective healthcare outcomes. Develops strategies and objectives within long-term care management to improve member and/or provider experience.
Key Details
This role leads a team of RN managers. We are looking for Registered Nurses with experience in Value-Based Care Management, especially in Child Welfare, Medicaid/Managed Care, CHIPS, STAR Kids, or STAR Health programs. Candidates should have at least 4+ years of leadership experience managing RNs in a managed care organization or a state government agency. Experience with data analysis, health informatics, clinical reporting, and change management is a plus. Candidates will need to travel occasionally to Austin, TX or Houston, TX for leadership meetings. Mileage reimbursement is provided for travel.
- Provides leadership to the development, implementation, monitoring, and ongoing improvement of the long-term care management process
- Sets goals and objectives for long-term care management team and oversees care management data and reporting metrics to achieve quality and cost-effective healthcare results and working with senior leadership, as required
- Leads long-term care management policies and procedures within the care management team to ensure compliance with corporate, state, and National Committee for Quality Assurance (NCQA) standards
- Oversees and monitors work assignments and caseloads of long-term care management staff based on state requirements, care management staff experience, and member needs
- Monitors, reviews, and signs off on contract required reporting as required
- Vendor oversight as required and applicable to the role
- Attends conferences and stays up to date on latest trends and best practices in Payer Care Management and related fields, as applicable
- Leads and presents process improvements for the long-term care management team to achieve cost-effective healthcare results
- Leads and coordinates large or special project work with other departmental functions
- Directs and evaluates departmental operations, including the long-term care management model, staffing, use of information technologies, onboarding, and staff competencies to achieve performance and quality objectives
- Reviews and monitors long-term care member data to identify trends and improve operating performance and quality care in accordance with state and federal regulations, and participates with internal and external audits as required
- Contributes to the development and improvement of clinical care pathways that enhance cost effectiveness while providing quality care
- Develops long-term care management strategies and influences decisions by providing recommendations that align to organizational objectives
- Provides coaching and guidance to long-term care management team to improve member and provider experience and facilitate delivery of high-quality care
- Develops department budget while collaborating inter-departmentally and with senior leadership
- Develops the overall strategy for onboarding, hiring, and training new long-term care management team members to ensure adequate training and high-quality care to improve member and/or provider experience and ensure compliance
- Performs other duties as assigned.
- Complies with all policies and standards.
Education/Experience
Positions overseeing RN team members and requires Graduate from an Accredited School of Nursing and 7+ years of related clinical nursing experience, including current or prior management experience or equivalent experience acquired through accomplishments of applicable knowledge, duties, scope and skill reflective of the level of this position, and current or prior management experience. BSN is preferred.
- 4+ years of direct RN managerial experience preferred.
- Expert knowledge of industry regulations, policies, and standards preferred.
- Highly advanced clinical knowledge and ability to assess member needs in context of relevant diagnoses, treatment plans and goals, and identify potential gaps in care or risks for readmission or complications preferred.
- Strong knowledge of healthcare managed care principles preferred.
- Experience working with providers and healthcare teams to develop appropriate long-term service plans/care plans preferred.
- Strong knowledge of medication indications and side effects preferred.
License/Certification
- Positions overseeing RN team members: Current state’s Registered Nurse (RN) license required or Compact Nursing License
- For Superior Health Plan: Resource Utilization Group (RUG) certification must be obtained within 90 days of hire. Must be RUG certified if overseeing RN team members required
NOTE: Position requires a Texas DFPS background check
Pay Range: $133,700.00 - $247,400.00 per year
Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.
Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act