The Case Management Program Specialist is responsible for program management of the Case and Utilization Management functions.This role facilitates the planning, organizing, and coordinating the activities of the Case Management Departmentâ€™s activities.Requirements include demonstrating mastery of the clinical and administrative requirements to meet all regulatory requirements of managing care within the health plan environment.This also includes an understanding of TRICARE, DoD, and USFHP standards and programs.This position includes daily clinical discretionary capacity that has potential to affect the financial well-being of the health plan.
Responsible for all aspects of the Case and Utilization Management programs, including:
Assessment, monitoring and leading training, development, and clinical competency of the associates working on case and utilization initiatives.
Facilitation of all reporting and report preparation functions related to the Case and Utilization Management Programs for the CHRISTUS Health Plan.
Ongoing compliance with existing contractual and regulatory standards within the Medical Management Department.
Ongoing evaluation and improvement of work processes, within department to ensure optimum potential of the department and Associates
Development, implementation, and evaluation of case and utilization management programs as part of annual strategic initiatives and reporting.
Collaboration with all departments within the Health Plan to assure understanding and compliance with all activities related to case, utilization and behavioral health.
Participation in work groups and committees oriented toward improving health plan operations.
Routine review of reports related to area of responsibility, providing feedback with regards to opportunities for improvement and related plans of action.
Assurance of the development and maintenance of policies and procedures for department.
Works closely with department and executive leaders in the Health Plan to identify and plan for opportunities for improvement within areas of responsibility.
Follow the CHRISTUS Guidelines related to the Health Insurance Portability and Accountability Act (HIPAA), designed to prevent or detect unauthorized disclosure of Protected Health Information (PHI).
Communication, Collaboration and Coordination with all customers, internal and external.
Assumes responsibility for professional development by attending educational seminars and or participating in written educational initiatives related to role.
Tracks applicable laws and regulations and ensures compliance.
Graduate of an accredited Nursing program, including RN, nurse practitioner, social work
Masterâ€™s level Degree
Computer application experience
Experience with word processing/spreadsheets
Excellent verbal and written skills
Minimum of three to five years clinical experience
Minimum three years program management experience
Experience in the development and facilitation of program based work
Current/Active Texas credentials in field of expertise
Ability to organize and prioritize work to meet deadlines.
Excellent critical thinking, interpersonal and problem solving skills.
Ability to work occasional long or irregular hours.
Excellent speaking ability, judgement, initiative and problem solving abilities.
Ability to handle and resolve complex issues.
Sedentary physical activity 2/3 of work time performing non-strenuous activities of an administrative nature.
Ability to read, analyze, and interpret reports.
Ability to interpret a variety of instructions furnished in written, oral or schedule form.
Ability to handle multiple tasks simultaneously.
Manual dexterity sufficient to work with the fingers and hands when performing administrative type duties.
Proficient in word processing and spreadsheet applications.
Meeting deadlines in high pressure environment
Ability to withstand intense human interaction.
Minimal overnight travel (up to 10%) by land and/or air.
CHRISTUS HEALTH is an international Catholic, faith-based, not-for-profit health system comprised of almost more than 600 services and facilities, including more than 60 hospitals and long-term care facilities, 350 clinics and outpatient centers, and dozens of other health ministries and ventures. CHRISTUS operates in 6 U.S. states, Colombia, Chile and 6 states in Mexico. To support our health care ministry, CHRISTUS Health employs approximately 45,000 Associates and has more than 15,000 physicians on medical staffs who provide care and support for patients. CHRISTUS Health is listed among the top ten largest Catholic health systems in the United States.