Job Description

  • PRIMARY FUNCTION
    • As a Care Manager, you will assist in the development, implementation, and operations of a comprehensive Care Management program in order to distinguish Pediatric Associates in the market on the basis of demonstrating health care quality, efficiency and interconnectivity for patient care management and coordination in support of the mission, core values, goals and objectives of Pediatric Associates.
  • ESSENTIAL FUNCTIONS OF THE JOB
    • This list may not include all of the duties that may be assigned.
       
    • Implements and monitors the case management program focused on population health management.
    • Develops and maintains an integrated clinical care management model that fosters appropriate levels of care and maximized reimbursement / cost savings.
    • Administers care management partnerships with commercial payers and other entities.
    • Establish innovative relationships with payers and employers that promote value and expand market share.
    • Serves as liaison between across the revenue cycle management departments to coordinate effective information flow related to payer contracts and reimbursement.
    • Informs patients regarding general preventative care practices as well as individualized care plans.
    • May keep track of and/or update patients' records, especially electronic records, and must keep current with computer technology, software, security measures, and legislation regarding patient privacy and other issues.
    • Monitors changes in a patient’s status and subsequent alterations to the care plan.
    • Helps implement measures to improve patient care.  Reviews utilization practices and facilitates positive changes to patient behaviors regarding their medical care.
  • PERFORMANCE REQUIREMENTS
    • Education:
      • A Bachelor’s degree in nursing or related field or combination of education and experience in care management, practice administration and/or managed care. Registered Nurse (RN) designation / license. Care management experience in managed care industry, physician group practice or health care required. Significant knowledge of care management, population health management and operational issues related to payers and networks, physician groups, and health insurance benefit plan designs.

    • Licensure:

    • Knowledge, Skills & Abilities:
      • Must have patient management skills.
      • Knowledge of medical billing and health records maintenance.
      • Knowledge of ICD-10, ICD-9, CPT and HCPCS coding.
      • Must have excellent interpersonal and communication skills.
      • Must have excellent decision making and problem solving skills.
      • Must be detail oriented and have good analytical skills.
      • Knowledge of laws governing the protection of patients’ private health information.
      • Substantial experience in managed care business development/financial management/consulting with an emphasis on population health and value based contracting.
      • Excellent clinical skills, operations and systems administration / analysis.
      • Demonstrated experience working effectively with payers, employers, state government, and other external influencers
      • Extensive knowledge of health care delivery, including business planning, operations and finances, coupled with an ability to effectively respond to elements to drive competitive advantages
      • Knowledge of emerging public health issues, health care inequities, health care financing, and health systems

    • Experience:

    • Adhere to all organizational information security policies and protect all sensitive information including but not limited to ePHI and PHI in accordance with organizational policy, Federal, State, and local regulations.

Application Instructions

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