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Resp & Qualifications

PURPOSE:

The position supports the Government Programs - Medicaid line of business and enrollees. Provides management and assessment of overall care management program for Medicaid enrollees from birth until age 65 when they transition to Medicare. Implements programs and initiatives to form a comprehensive and cohesive model that effectively identifies high-risk members. Manages the delivery of effective interventions, and tracks outcomes across the organization, ensuring compliance with regulatory requirements. Manages and evaluates care management services offered and works closely with leadership, physicians/providers, and other service lines. We are looking for an experienced clinical leader in the greater Baltimore metropolitan area who is willing and able to work in a hybrid model. The incumbent will be expected to work a portion of their week from home and a portion of their week at a CareFirst location based on business needs and work activities/deliverables that week.

ESSENTIAL FUNCTIONS:

+ Manages and develops and maintains quality-improvement programs to optimize patient care.

+ Collaborates with physicians, nursing and hospital leaders to ensure service expectations are being met.

+ Manages care management staff. Develops and leads team.

+ Conducts care coordination activities including case management and disease management.

QUALIFICATIONS:

**Education Level:** Bachelor's Degree, Nursing OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.

**Experience:** 5 years care management experience.1-year supervisory experience or demonstrated progressive leadership experience. Must have specific experience with Medicaid line of business and related regulations.

Licenses/Certifications

Health Services\RN - Registered Nurse - State Licensure and/or Compact State Licensure Upon Hire Required

Preferred Qualifications

+ Solid understanding for COMAR regulations and knowledge of NCQA.

Knowledge, Skills and Abilities (KSAs)

+ Ability to communicate effectively verbally and in writing.

+ Knowledge of health benefits industry, products, trends, consumer market, and competitive intelligence.

+ Knowledge and proficiency in use of metrics and measures in managing programs and services.

+ Strong organizational skills to manage multiple projects, issues and priorities.

+ Basic understanding of the strategic and financial goals of a health care system or payor organization, as well as health plan or health insurance operations (e.g. networks, eligibility, benefits).

+ Knowledge of managed care principles and concepts including Health Plan Employer Data and Information Sheet (HEDIS) and knowledge of the standards of practice for case manager. **Salary Range** : $96,160 - $178,497

Salary Range Disclaimer

The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilites of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).

Department

CHPMD Medicaid

Equal Employment Opportunity

CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

Where To Apply

Please visit our website to apply: www.carefirst.com/careers

Federal Disc/Physical Demand

Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on health care programs.

PHYSICAL DEMANDS:

The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.

Sponsorship in US

Must be eligible to work in the U.S. without Sponsorship.

\#LI-NH2

REQNUMBER: 21133