Care Management Department Manager

Group Health Cooperative of South Central Wisconsin. BETTER TOGETHER

The Care Management Manager's responsibilities ensure that the UM department operates efficiently, improving patient outcomes and reducing unnecessary healthcare costs. The Care Management Manager is responsible for the overall operations of the Care Management Department in conducting a program of case management and utilization review for medical and behavioral health. This includes hospital utilization control, discharge planning, consultant referral authorization, pre-operative coordination, second review of claims, case management and DME authorization/utilization. The incumbent ensures the integration of care management policies and procedures. They ensure that medical and behavioral health care services are medically necessary, appropriate and provided in the most cost-effective setting. Work is performed under the general direction, guidance, and supervision of the Chief Medical Officer.

GHC-SCW is a quality driven cooperative built on collaboration, community involvement, innovation, and belonging. In dedication to the health and well-being of our employees, we offer a comprehensive benefits package that includes health and dental insurance, along with paid short-term disability, long-term disability, and life insurance. Additional benefits include a flexible spending account, employee assistance programs, tuition reimbursement, pet insurance, eyewear discounts, and more. Check us out by clicking on Many Talents, One Mission! The Benefits of Working at GHC-SCW.

Job Specific Minimum Qualifications

1. Bachelor of Science degree in nursing from an accredited college or university; or equivalent combination or education and work experience in case management /utilization review required. Master's degree in nursing or relevant major preferred.
2. Unrestricted license to practice in the State of Wisconsin as a Registered Nurse required.
3. Possession of Managed Care Nurse Certification (CMCN, CCM or relevant certificate) is desirable. Certification must be obtained within twelve (12) months from the date of hire.
4. Possession of a valid Wisconsin Driver License with good driving record. Ability to provide personal transportation as needed.
5. Minimum of five (5) to seven (7) years' experience in case management, discharge planning/ utilization review is required Previous experience in a managed care environment, an acute or ambulatory care setting and/or home care setting preferred.
6. Previous supervisory or management level experience preferred. Strong leadership experience is required.
7. Working knowledge of healthcare administration in a managed care environment. Knowledge of legal and legislative procedures, terminology and issues as they pertain to healthcare. Knowledge of NCQA or JCAHO accreditation processes.
8. Thorough knowledge of nursing principles, methods and techniques required. Ability to maintain currency in utilization-review/discharge planning practices required. Possession of an awareness of new development and trends in managed care, and case and utilization management required.
9. Knowledge of the principles and practices of supervision and administration as applied to the management of personnel and departmental operations. Ability to manage conflict, delegate tasks, supervise professional staff and manage department budget required. Ability to provide individual and group counseling and guidance to departmental staff required
10. Knowledge of and proven proficiency using computers including the use of Microsoft Office applications including word processing, spreadsheet, and database management. Knowledge of or ability to learn electronic medical record systems for the purpose of reviewing medical records and electronic insurance systems. Experience with EPIC insurance modules is desirable but not required.
11. Knowledge of mathematical, algebraic, and statistical concepts for data analysis and presentation.
12. Outstanding verbal and written communication skills including ability to provide telephone support and consult with external parties, practitioners, and internal staff required.
13. Excellent customer service and interpersonal skills to deal courteously and effectively with internal and external staff, members, vendors, employer groups and the public. Ability to work with diverse member, employer and provider populations. Ability to work effectively with the managers and staff of various GHC-SCW departments. Ability to represent GHC-SCW in a professional manner required. Excellent interpersonal skills and the ability to interact well and maintain excellent working relationships with staff at all levels required.
14. Excellent organizational skills, prioritization skills; and analytical and problem-solving ability required. Ability to pay attention to details and successfully manage multiple tasks and projects.
15. Ability to effectively function as a team player.
16. Ability to maintain patient and organizational confidentiality required. Knowledge of HIPAA requirements.
17. Self-motivation and self-direction required; capable of working independently and with limited direct supervision required.
18. Ability to sit, stand, walk, and drive on a regular basis required. Ability to operate a computer keyboard daily required.
19. Ability to work irregular hours when needed required.

The incumbent knows and abides by all GHC-SCW organizational and departmental policies, sets personal standards and strives for high quality work in completing assignments, performs job duties in a timely manner, and represents the organization in a positive manner.

Our Mission Statement: We partner with members and the communities we serve to maximize health and well-being.

Our Vision: As a local, not-for-profit, member-owned Cooperative, we are the most trusted resource for lifelong health and well-being in the communities we serve.

Our Values:

• We are a not-for-profit Cooperative
• We are member-centered
• We are equitable and inclusive
• We are quality-driven
• We are innovative
• We are community involved

We believe:

Healthcare is a human right.

In treating all people with dignity and respect.

There is strength in diversity.

Equity celebrates our humanity.

We are better together.

Group Health Cooperative of South Central Wisconsin is proud to be an equal opportunity employer. GHC-SCW considers candidates regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.