You Make Us Grow. You Make Us Sharp.

Hours:

Shift Start Time:

8 AM

Shift End Time:

5 PM

AWS Hours Requirement:

8/40 - 8 Hour Shift

Additional Shift Information:

Weekend Requirements:

As Needed

On-Call Required:

No

Hourly Pay Range (Minimum - Midpoint - Maximum):

$67.189 - $86.695 - $106.201

The stated pay scale reflects the range that Sharp reasonably expects to pay for this position.  The actual pay rate and pay grade for this position will be dependent on a variety of factors, including an applicant’s years of experience, unique skills and abilities, education, alignment with similar internal candidates, marketplace factors, other requirements for the position, and employer business practices.

What You Will Do
Under the direction of the Sharp Community Medical Group (SCMG) Director for Health Service and in collaboration with the Health Services leadership team, this position is accountable for the development and implementation of an effective Hospital Case Management program (HCM) and Ambulatory Case Management (ACM) program that encompasses a patient centered care management approach that includes referral management, prior authorization, Case Management and Disease Care Management and Pharmacy. Manages the operations of the Hospital Case Management program and Ambulatory Case Management (ACM) Department and is responsible for the execution and coordination of all ACM activities including Pharmacy. Helps to plan, develop, organize, monitor, communicate and recommend modifications to the HCM Program, ACM Program and Pharmacy Program including all HCM, ACM and Pharmacy policies and procedures. Coordinates interdepartmental projects to assure quality outcomes. Develops and implements operational policies and procedures that have a direct impact on the HCM and ACM programs in accordance with NCQA standards, legislative, and contracted health plan requirements. Provides direct supervision of the HCM and ACM staff and models effective leadership and mentoring skills. Promotes staff development using the concepts and tools supporting the Sharp Experience. Collaborates with Sharp Management team to facilitate internal and external committees and/or initiatives to address quality improvement as a representative of SCMG. Provides support to the VP for Clinical Operations and HS leadership team to ensure regulatory and legislative compliance for the division. Under the direction of the SCMG Director for Health Services, develops financial (budget) and operational strategy of HCM and ACM Departments.

Required Qualifications

• Bachelor's Degree in Nursing Or
• Bachelor's Degree in Healthcare Administration.
• California Registered Nurse (RN) - CA Board of Registered Nursing -REQUIRED

Preferred Qualifications

• Master's Degree in nursing, healthcare, quality, or business.
• 5 Years clinical nursing experience in acute care hospital setting.
• 2 Years management, service line or program experience.
• Certified Professional in Healthcare Quality (CPHQ) - National Association for Healthcare Quality -PREFERRED
• Certified Case Manager (CCM) - Commission for Case Manager Certification -PREFERRED

Other Qualification Requirements

• Other relevant QM/UM/CM certification preferred.

Essential Functions

• Supervisory
  Develops and implements policies and procedures that have direct impact on the Hospital Case Management, Ambulatory Case Management and Pharmacy programs in day to day operations.
  Provides direction and leadership to the Hospital Case Management, Complex Case Management, Disease Management and Pharmacy program staff.
  Promotes consistency, communication, fairness and respect within the department for all employees.
  Adheres to Sharp Healthcare human resources policies and ensures timely evaluation for employees per Sharp Healthcare policies.
  Establishes goals and objectives for each direct report in compliance with performance management policies.
  Maintains consistent follow-up with direct reports to support attainment of goals set.
  Develops, facilitates and updates training programs throughout SCMG to ensure staff has knowledge that allows them to complete their assigned tasks.
• Compliance
  Manages HCM, ACM and Pharmacy operations in accordance with National Committee on Quality Assurance (NCQA) and Health Plan requirements and ensures that new requirements are identified on a timely basis.
  Collaborates with SCMG Management and HSM Management staff in quality related activates to ensure compliance with health plan contracts, legislative policies and SCMG specific requirements.
  Works with SCMG Management, HSM lead, supervisor and staff to identify issues and initiate improvements.
  Works with Director, Health Services and VP for Clinical operations and Health Services to ensure timely submission of required Utilization, Case Management and Disease Management Work plans to Health plans; if required submits corrective action plans within agreed upon time frames.
  Ensures appropriate and timely compliance with quality and compliance requirements.
  Develops and enforce policies and procedures for HSM that involve Case Management and UM.
  Serves as the SCMG HCM/ACM liaison to outside compliance agencies to ensure collaboration with other Med Groups and Health plans (i.e. ICE, IHA, NCQA).
• Financial
  Develops, monitors, and maintains unit budget within approved limits.
  Responsible for identification and implementation of cost savings strategies.
  Maintains an excellent understanding of health plan incentives targeted at efficiency measures, i.e. Pay for Performance, 5 STAR, HEDIS and health plan specific programs, etc. and implements processes to achieve SCMG targets.
  Supports development and implementation of initiatives and strategies targeted at maximizing group performance in incentive programs such as IHA’s Pay for Performance Program etc.
• Reporting and Data Analysis
  Implementation and maintenance of a regular reporting system for operational and quality outcome indicators.
  Analyzes and implements actions plans using these reports to measure and improve patient care outcomes and operational efficiency and effectiveness.
  Reports key performance measurement and quality improvement initiative results to the Quality of Care Committee.

Knowledge, Skills, and Abilities

• Demonstrated working knowledge of managed care, capitation, provider payment mechanisms and member benefits.
• Demonstrated experience and the ability to lead staff and daily operations.
• Demonstrated ability to develop, implement and monitor program direction and continuous performance improvement initiatives.
• Excellent written and verbal communication skills, customer service skills and leadership skills.
• Strong working knowledge of clinical practice and medical necessity guidelines.
• Strong analytical, problem solving, concurrent and retrospective data management and computer skills.
• Ability to establish good working relationships with all levels of support staff, providers, administrative staff and all other internal and external customers.
• Demonstrated positive personal influences on teams and customers including the willingness to accept change proactively.
• Demonstrated ability to be flexible and responsive to needs of organization and possess ability to balance the needs of multiple priorities.

Sharp HealthCare is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender, gender identity, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified individual with disability or any other protected class

Bachelor's Degree in Nursing; Bachelor's Degree; Master's Degree; California Registered Nurse (RN) - CA Board of Registered Nursing; Certified Professional in Healthcare Quality (CPHQ) - National Association for Healthcare Quality; Certified Case Manager (CCM) - Commission for Case Manager Certification