Supervisor, Outpatient Case Management- San Diego at Prospect Medical Holdings, Inc. in Orange, California

Job Description:

The Supervisor, Outpatient Case Management has accountability for the direct, daily supervision of case managers' and coordinators' work with members, documentation of interventions, and reporting of activities per established protocols. The CM Supervisor maintains visibility to the outpatient CM team and provides "real time" CM guidance and direction as appropriate.With approximately 9,000 physicians to serve our 260,000 members, Prospect Medical Systems is proud to be among the most innovative medical systems in California, Texas and Rhode Island. Our extensive care services range from primary care and specialty physician services to acute care hospital and skilled nursing facilities to behavioral health and wellness services. Each of our Independent Physician Associations (IPAs) and networks support the use of advanced diagnostic and treatment tools to provide our members with convenient access to state-of-the-art healthcare. For 25+ years, Prospect Medical has been focused on our mission of supporting independent physicians where, through risk arrangements, we work closely together with health plans, facilities and healthcare physicians for the benefit of every person who comes to us for care. We provide quality healthcare services that are designed to offer our patients highly coordinated, personalized care and that help them live healthier lives. Prospect Medical Systems manages highly successful IPAs by leveraging our best-practices, results-driven administrative services to manage patients under risk arrangements with health plans/CMS.Minimum Education: Bachelor's Degree of Science in Nursing and other related fields or higher preferred.

Minimum Experience: Two plus (2+) years of Case management or other similar programs experience in managed care required. Strong leadership skills with the ability to influence, manage, and motivate personnel. Must have analytical ability for problem identification and assessment and evaluation of data/statistics obtained from an on-going review process. Capable of resolving escalated issues arising from operations and requiring coordination with other departments. Ability to prioritize and multi-task. Able to work independently and make independent clinical and non-clinical decisions. Excellent communication skills. Maintain professional attitude when working with internal and external customers. Adeptly utilize computer programs - both Microsoft Office applications and job-specific electronic software applications. Maintain and ensure confidentiality of patient information. Three plus (3+) years demonstrated leadership and team management/development skills preferred. Experience in health plan audits and compliance is a plus.

Req. Certification/Licensure: RN unrestricted active license required. Will consider LVN with supervisory experience in managed care. Knowledgeable in managed care, Medicare, Medicaid regulations, Model of Care and Case Management requirements.

• Oversees the process, management, and reporting of Outpatient Case Management activities with focus on health plan compliance and decreasing utilization.


• Works with the CM leadership to contribute to the development of CM processes and procedures as needed to ensure process compliance and improvement


• Conducts internal audits of case management for Outpatient CM cases, provides feedback and coaching's to staff as needed


• Monitors and evaluates effectiveness of the case management plan and modifies as necessary to meet regulatory requirements to include all required elements. This includes coordinating services, evaluating treatments, intervening in crisis and provide general support.


• Hires, trains, coaches, and evaluates the performance of direct reports.


• Identify educational needs and provide training and educational resources for current and incoming staff.


• Responsible for achieving quality and productivity standards and for ensuring compliance with department policies and procedures


• Improves on the effectiveness and efficiency of Outpatient CM staff, through process improvements activities.


• Provides leadership and supervision to case managers, and care coordinators.


• Participate in Health Network oversight activities, as assigned and required


• Maintain knowledge of current regulatory NCQA, CMS, and DMHC requirements and industry trends


• Assists with submission deliverables for health plan audits


• Oversees internal department meetings (Interdisciplinary care team (ICT) meeting, team huddles, etc.) as applicable.


• Other projects and duties as assigned by department Manager and Director.

Job Location: This position requires 20% Field Responsibilities within the San Diego area.

• Oversees the process, management, and reporting of Outpatient Case Management activities with focus on health plan compliance and decreasing utilization.


• Works with the CM leadership to contribute to the development of CM processes and procedures as needed to ensure process compliance and improvement


• Conducts internal audits of case management for Outpatient CM cases, provides feedback and coaching's to staff as needed


• Monitors and evaluates effectiveness of the case management plan and modifies as necessary to meet regulatory requirements to include all required elements. This includes coordinating services, evaluating treatments, intervening in crisis and provide general support.


• Hires, trains, coaches, and evaluates the performance of direct reports.


• Identify educational needs and provide training and educational resources for current and incoming staff.


• Responsible for achieving quality and productivity standards and for ensuring compliance with department policies and procedures


• Improves on the effectiveness and efficiency of Outpatient CM staff, through process improvements activities.


• Provides leadership and supervision to case managers, and care coordinators.


• Participate in Health Network oversight activities, as assigned and required


• Maintain knowledge of current regulatory NCQA, CMS, and DMHC requirements and industry trends


• Assists with submission deliverables for health plan audits


• Oversees internal department meetings (Interdisciplinary care team (ICT) meeting, team huddles, etc.) as applicable.


• Other projects and duties as assigned by department Manager and Director.

Job Location: This position requires 20% Field Responsibilities within the San Diego area.

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