Posted on: May 1, 2021
Your career starts now. We’re looking for the next generation of
health care leaders.
At AmeriHealth Caritas, we’re passionate about helping people get
care, stay well and build healthy communities. As one of the
nation's leaders in health care solutions, we offer our associates
the opportunity to impact the lives of millions of people through
our national footprint of products, services and award-winning
programs. AmeriHealth Caritas is seeking talented, passionate
individuals to join our team. Together we can build healthier
communities. If you want to make a difference, we’d like to hear
Headquartered in Philadelphia, AmeriHealth Caritas is a
mission-driven organization with more than 30 years of experience.
We deliver comprehensive, outcomes-driven care to those who need it
most. We offer integrated managed care products, pharmaceutical
benefit management and specialty pharmacy services, behavioral
health services, and other administrative services. Discover more
about us at www.amerihealthcaritas.com.
Responsible for providing oversight and administrative
management of the Care Management Department and related teams,
care plan development, and care plan implementation.
Direct activities of the Care Management / Utilization
Management staff. Oversee staff performance with regard to prior
authorization, medical necessity determinations, concurrent review,
retrospective review, continuity of care, care coordination, and
other clinical and medical management programs. These
responsibilities extend to physical and behavioral health care and
Ensure effective daily operation of the Care Management
Department utilizing all applicable statutory provisions, contracts
and established policies and administrative procedures.
Maintain optimal staffing patterns based on contractual
obligations and current Care Management budget. Comply with all
policies and procedures for personnel requisitions, interviews and
employment. Maintain accurate position control and organizational
chats of assigned departments.
Participate in the State’s Drug Utilization Review (DUR) Board
Meeting and Mental Health Quality Assurance Committee.
Partake in internal pharmacy therapeutic committee and work
closely with the Directors of Pharmacy, pharmacy benefits manager
(PBM), and the State’s PBM team.
Prepare reports and conduct analysis of operations /
services as required by departmental, corporate, regulatory, and
State requirements. Work collaboratively with Information Services
Department on identifying required data for reporting.
Assist in preparation, coordination, and follow up of Care
Management audits, such as readiness review and OMPP site visits,
pertaining to the Care Management Department.
Partner with community agencies and contracted vendors to
develop and maintain collaborative contact to assure members have
access to the appropriate resources and to avoid duplication of
Act as a liaison with outside entities, including but not
limited to physicians, hospital, health care vendors. social
services agencies, member advocates, OMPP and other Care Select
Participate in coordination of internal and external Provider
and Member directed communication regarding issues impacting Care
Management coordination and delivery, such as medication
management, use of generic medications, etc.
Establish performance and productivity requirements and
communicate expectations to management team. Work collaboratively
with Supervisor in identification of individual and / or group
deficiencies in scheduled Performances Reviews. Establish action
plan for assessment and resolution of identified issues.
Oversee the collaborative efforts of the Supervisors to ensure
that all new and existing staff are oriented to organizational and
department policies and procedures. Ensure that credentials of all
licensed staff are verified in accordance with licensing agency
initially and prior to expiration date. Maintain current and
accurate files of such licensure and ongoing education status.
Ensure that staff meets minimal skill and clinical knowledge
requirements to be successful in assigned role.
Participate in current process review and development of new
and / or revised work processes, policies and procedures relating
to Care Management responsibilities. Provide input into the
development of educational material and programs necessary to meet
business objectives, members’ needs, contractual and regulatory
guidelines and staff professional development.
Comply with Corporate, Federal, and State confidentiality
standards to ensure the appropriate protection of member
identifiable health information
Develop and maintain department budget. Seek opportunities to
Current unrestricted RN Licensure required.
Case management certification preferred, those seeking case
management certification considered.
Professional certification in a clinical specialty needed.
Experience in use of financial information for planning
Valid Driver’s license and clean driving record required;
reliable transportation and appropriate auto insurance
Demonstrated ability to assess department’s work quality and
develop/implement process improvements to achieve contractual and
Maintain a current knowledge of company policy and procedures,
OMPP Requirements, NCQA/URAC recommendations impacting Care
Management assessment, access and delivery of services.
Maintain understanding of managed care and Care Management role and
impact on services including but not limited to, prior
authorization, inpatient review, discharge planning, home health,
and SNF/Rehabilitation Services.
Demonstrated competency in use of healthcare data.
Three years case management experience in relevant scope
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