Care Mgmt. Team Lead Nurse RN

Community Health Choice, Inc. (Community) is a non-profit managed care organization (MCO), licensed by the Texas Department of Insurance. Through its network of more than 10,000 providers and 94 hospitals, Community serves over 400,000 Members with the following programs:

' Medicaid State of Texas Access Reform (STAR) program for low-income children and pregnant women

' Children's Health Insurance Program (CHIP) for the children of low-income parents, which includes CHIP Perinatal benefits for unborn children of pregnant women who do not qualify for Medicaid STAR

' Health Insurance Marketplace Plans that offer individual health coverage that includes preventive care, emergency services, prescription drugs, and hospitalization available to all, regardless of pre-existing conditions.

' Community Health Choice (HMO D-SNP), a Medicare Advantage Dual Special Needs plan for people with both Medicare and Medicaid that combines Medicare Part A and Part B benefits, Medicare Part D prescription drug coverage, and Medicaid benefits with additional health benefits like dental, vision, transportation, and more.

Improving Members' experiences is at the heart of every Community position. We strive every day to make sure that our Members have access to the high-quality health care they need and deserve.

Community is accredited by URAC for its health plan operations. We offer care management programs for asthma, diabetes, and high-risk pregnancy. An affiliate of the Harris Health System (Harris Health), Community is financially self-sufficient and receives no financial support from Harris Health or from Harris County taxpayers.

JOB SUMMARY

Care Management Team Lead Nurse RN will manage CHC members with chronic diseases, conditions, or medically complicated needs through comprehensive evaluation and through coordination of resources. The Care Manager Team Leader will participate as a team member in CHC Care Management program. Care Managers will work collaboratively with utilization management, member services and the quality improvement departments.

JOB SPECIFICATIONS AND CORE COMPETENCIES

Manages abbreviated caseload to maintain expert knowledge in care management processes. Identification and contact potential members for any of the Care Management Programs within the program time frame. Participation in member events, baby showers and health fairs in collaboration with CHC outreach staff. Perform assessment of identified members for Care Management Services within the program time frame. Complete Risk Stratification on enrolled members in CM Programs within the program time frame.

Contact providers of enrolled members within the CM program specification. Develop Care Management action plans for members within the Care Management Programs in collaboration with members and providers within the program time frame. Input of authorizations for Home Health Agencies and DME companies to facilitate member/provider request for supplies and services. Monitor events and outcomes of members within the Care Management Program in relation to the action plans. Record Care Management activities and contacts within the Care Management Module on a routine and timely basis within the program time frame.

Coordinates daily operational aspects of team and assists manager with staff supervision. Monitors and facilitates equal distribution of workload assignments. Assists manager in setting productivity goals. Monitors Coordinators and Care Managers to ensure performance and productivity. Reviews and documents staff productivity on monthly and ad hoc basis. Informs manager about escalated issues and works with manager to resolve them. Monitors adherence to attendance, PTO, lunch, and break guidelines.

Quality/Process Improvement. Provides information for employee performance reviews. Ensures that staff completes required trainings. Holds monthly team meetings with staff and documents minutes. Evaluations of team members and any necessary improvement plans. Completes documentation and call monitoring audits quarterly and ad hoc. Identifies training needs. Assists with new and ongoing employee training and development of training documents. Identifies opportunities for process and productivity improvement and shares with manager. Coaches and mentors' staff on issues identified.

Assist with Program Management Development and/or redesign of Care Management Program. Recommend improvements to the Care Management Program Development. Maintain and report required Program Analytic requirements. Development of program related member outreach and educational activities

Actively contributes to achievement of departmental goals, as identified in Department's annual business plan, including specific departmental process improvement plans. Other duties as assigned.

QUALIFICATIONS:

Education/Specialized Training/Licensure: Associates Degree required.

RN current Texas License required

Certification in Clinical Case Management (CCM) required.

Bachelors Degree preferred.

Work Experience (Years and Area): 3 years of clinical experience plus 1 year

Managed Care experience 1 year case management experience

Software Proficiencies: Microsoft Office (Word, Excel, Outlook)

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