Manager, Care Coordination and Utilization Management

Denver, CO, United States

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Job Description:

The Manager, Care Coordination and Utilization Management is responsible for the operations of the continuum of care management, including both care coordination and utilization management. This position is responsible for leading the development, implementation, and evaluation of care management health initiatives aimed at improving health outcomes and reducing healthcare costs for defined populations. This role requires a strategic thinker with a deep understanding of population health principles, utilization management, healthcare delivery systems, and data-driven decision-making.

Essential Functions:

Manages day-to-day operations of the department and employees, recognized problems, and systematically gathers information to help solve problems and improve employee satisfaction

Leads a team of nurses, social workers, and non-clinical staff, including addressing performance problems decisively and objectively, provides guidance and assistance to improve performance, rewards hard work and risk-taking, motivates, challenges, develops employees, and delegates effectively.

Uses resources efficiently, always looking for ways to reduce costs, creates accurate and realistic budgets, tracks and adjusts budgets, and contributes to budget planning

Works cross-departmentally with PHP, Alpine Associates, and new markets to provide leadership and direction on program design, implementation, and evaluation, including traveling and interacting with local markets.

Aligns and oversees care management activities to support success with organizational key objectives

Provides analysis and utilizes program data to include making suggestions for and implementing clinical process changes, improvements, program design and implementation of new initiatives and programs.

Conduct audits and assessments of healthcare services provided to delegated populations, ensuring compliance with regulatory requirements, contractual agreements, and quality standards.

Monitor delegated entities' adherence to regulatory requirements, accreditation standards, and contractual provisions through ongoing audits, reviews, and follow-up activities.

Facilitate communication among with primary care providers both virtually and in-person across all markets to promote positive patient outcomes and continuity of care.

Participates in and represents Care Coordination in workgroups such as monthly JOC’s, client-based meetings, and other internal and external committees.

Adheres to the company’s Compliance Program and to federal and state laws and regulations

Other duties as assigned

Only for job posting

This position is a full-time, hybrid role, who is also be expected to meet with community members.

Knowledge, Skills and Abilities:

Knowledge of people management including mentoring, motivation, and conflict resolution

Excellent project management and organizational skills

Ability to sort through complex issues, make appropriate, timely decisions, and communicate decisions to others

Knowledge of other roles and perspectives

Excellent written and oral communication skills

Exceptional presentation skills

Familiarity with care coordination models, principles, and best practices aimed at improving care transitions, enhancing patient outcomes, and reducing healthcare costs.

Understanding of healthcare delivery systems, including hospitals, clinics, long-term care facilities, and community-based services.

Ability to leverage data analytics tools to identify trends, track outcomes, and optimize care delivery

Ability to provide culturally competent care and tailor interventions to meet the unique needs of diverse populations.

Qualifications:

Education requirements

Graduate of accredited school of nursing with RN, Licensed Clinical Social Worker, or Masters level health care related degree.

3- 5 years’ clinical experience as RN or Licensed Clinical Social Worker, or Master’s level health care related degree.

3- 5 years’ experience in management of healthcare related staff

3-5 years’ experience supervising professional staff

3- 5 years’ experience in program design, implementation, and evaluation

Experience with commercial health insurance plans preferred

Knowledge of NCQA, QA, Medicare/Medicaid guidelines, program and workflow development, process improvement and implementation procedures, care coordination, especially care transitions models and health coaching models

Skilled in exercising a high degree of initiative to achieve organizational objectives

Skilled in teaching others and acting as a subject matter expert, motivational Interviewing, judgment and decision-making, customer service by being able to relate well to all kinds of people inside and outside the organization, builds appropriate rapport, uses diplomacy and tact, can diffuse even high-tension situations comfortably

Able to perform intermediate level of competence with various computer software applications including MS Outlook, Word, Excel, Access, and Power Point

Home office that is HIPAA compliant for all remote or telecommuting positions as outlined by the company policies and procedures

Salary Range:

$90,016 - $112,519

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