Manager, Coordinated Care Duals

Reporting to the Sr Director, Coordinated Whole Health Care the Manager of Coordinated Care will lead the services for the Health Plan which provide individualized health improvement for members while achieving strategic and regulatory objectives for the Plan for a line of business. Lines of business include Medicaid, Commercial, and Medicare Advantage.

They will develop integration with the delivery system. They will model process improvement and be a positive change agent within MGB Health Plan and the broader MGB system.

The successful candidate will have excellent staff management skills, written and verbal communication skills, as well as a deep understanding of case management and transitions of care.

Duties and Responsibilities:

Ensure regulatory standards related to coordinated care are achieved for Dual Eligible progams

• Deep understanding of the contractual and regulatory requirements for the DSNP line of business with ability to interpret, operationalize, and monitor execution of those requirements
• Maintain department CM standards and adherence to Case Management Society of America principles
• Promote and ensure staff compliance with care management system documentation
• Promote professional practice standards and maintenance of specialty credentials (e.g. CCM)
• Achieve NCQA requirements as applicable for Plan

Provide clinical and operational oversight of coordinated care functions

• Provide medical, social and behavioral care management to members
• Coordinate case review forums to guide and support development of care management plans which meet members' needs in the most cost-effective manner possible
• Resolve escalated cases from stakeholders within and outside of MGB Health Plan
• Work with Managers and Directors to develop and monitor key performance indicators and metrics
• Participate in vendor management processes including oversight of day-to-day operations and improvement opportunities
• Build strong customer relationships and meet customer expectations
• Collaborate with other members of the clinical team to provide a seamless experience for members and MGB HP staff

Manage staff and promote positive culture in Clinical department

• Oversee RNs, LICSWs, and other clinical staff for coordinated care
• Recruit and retain high performing team members
• Ensure resources are deployed to highest value functions
• Establish and meet internal key performance indicators
• Encourage and facilitate staff growth and development
• Promote a team environment
• Model and promote effective change management techniques
• Implement and standardize best practices such as process maps, root cause analysis, and Lean methodologies

Actively manage coordinated care for line of business, ensuring superior member experience, high quality care and trend management

• Gather market data on benchmarks, innovations, and processes from industry leaders and associations
• Lead performance management within MGB HP for coordinated care function
  • Report on quality and trend with assistance from analytic teams
  • Engage stakeholders in strategic review and future planning
• Achieve client-specific performance guarantees

Support sales and product in delivering market leading services for coordinated care

• Reduce the cost of care while maintaining quality by reviewing utilization trends, readmission rates and causes
• Support RFPs and create other materials for new and existing clients
• Develop business cases for new services
• Implement programs which utilize people and technology to offer unique value
• Promote continuous improvement for existing services
• Identify opportunities for use of technology

Increase integration between Mass General Plan and delivery system

• Establish positive relationships with delivery system leaders
• Enhance credibility of Plan
• Develop service levels, key performance indicators and targets for individual and shared activities
• Promote a seamless experience for our members
• Identify, share and implement best practices
• Leverage unique skills and strengths within each area
• Build efficiencies between teams

Foster collaborative relationships with customers and stakeholders

• Provide leadership and oversight in a way that promotes a supportive, respectful environment
• Develop effective relationships with leaders and staff in the Health Plan and with Population Health Management
• Present ideas, updates, findings, reports, recommendations, data, and analysis to various audiences to build consensus on clinical initiatives

Other duties as assigned

Qualifications:

• Required:
  • Valid unrestricted professional licensure as a Registered Nurse in Massachusetts.
  • Bachelor's Degree Nursing required, or equivalent combination of training and experience will be considered in lieu of a BSN.
  • At least 7-10 years clinical or related experience with minimum 3 years supervisory/management experience.
  • Experience presenting to senior leadership
• Preferred/Desired:
  • 3-5 years Health Insurance or Managed Care experience, with focus of DSNP.
  • Case management certification.
  • Master's degree in nursing or health health-related field.

Skills/Abilities/Competencies:

• Communication: verbal and written proficiency.
• Demonstrate the ability to multi-task and problem solve.
• Expertise in staff management, coaching and motivation.
• Strong collaboration and team-building skills.
• Competence in: care planning activities, documentation, health plan benefit management, regulations/compliance.
• Work with minimal direct supervision.
• Web-based research, analytic ability, project management, and computer proficiency.
• Demonstrate Mass General Brigham Health Plan's core brand principles of always listening, challenging conventions, and providing value.
• Bring fresh ideas forward by listening to and working with employees and the people we serve.
• Strong, demonstrated track record of the ability to execute on time, on budget, and on scope.
• Demonstrated forward, visionary thinking; ability to see "what is" and envision "what could be."
• Ability to develop, introduce, defend, and gain support for new ideas and approaches.
• Ability to translate and communicate complex topics in a variety of forums, tailoring communications to effectively fit and influence the targeted audience, strong executive presence, presentation, and communication skills.
• Ability to view the long-range trends and cycles of the business and industry and see the "big picture."
• Ability to apply a variety of strategic frameworks to analyze problems and to guide and develop solutions.
• Ability to challenge the status quo and drive innovative thinking and the capability to successfully implement strategy.
• Unquestionable integrity.

Supervisory Responsibilities:

• This role is for a new product line/team so it will include heavy recruitment responsibilities (including hiring 3 supervisors and 20 indirect reports)

Working Conditions:

• Normal office working conditions.
• Remote, Hybrid or onsite.
• Occasional travel may be required.