Manager - Operations - Sr. Care Manager

Location: Pensacola, FL


Title: Supervisor, Care Management

Care Management

SUMMARY: The Care Management Supervisor is responsible
for coordinating, monitoring, evaluating, and facilitating high quality, cost
effective care related to medical/care management. Assists in the development, organization,
direction and maintenance of all Care Management functions for
Members/Policyholders. The Supervisor
provides oversight in the day-to-day care management activities and works
independently with little supervision.

DUTIES AND RESPONSIBILITIES include the following. Other duties may be

care services for members/policyholders as prescribed by the departments’
policy and medical necessity of the member/policyholder.Assists
in monitoring of member, physician, and provider satisfaction by overseeing
those conducting satisfaction surveys, documenting, researching, and resolving
complaints and forwarding information to Director of the department.Monitors
referrals and care management activities by adjusting staffing and work
assignments as needed to maintain productivity standards.Maintains
appropriate levels of utilization.
Assists in analyzing utilization reports and developing strategies for
operational improvements as needed.Assists
in implementation of operational changes in order to improve efficiency of
processes and meet the department’s strategic goals.Serves
as a clinical resource to the care managers and other non-clinical staffResolves
complaints in a positive manner with tact and diplomacy within established time
monitors status and impact of care coordination, care management and adjusts
plan accordingly.Maintains
awareness of federal legislation effective care management services.Ensures
clinical staff complies with department, carrier, and CHCS policies and
for orienting, training, counseling, and terminating staff, when needed.Conduct
employee performance evaluations in a timely manner when needed and forward
information to Director.Functions
as a facilitator with regard to workplace departmental issues.Promotes
overall organizational and financial goals as well as improvement in overall
quality of the health care as the primary goal of any initiative.Responsible
for the daily management of appointed staff and work in collaboration with
other departments to achieve outcome goals for member/policyholder health and
wellness, chronic condition, and care management.Interacts
with Provider Network Department to promote coordinated approach and support
each department’s initiatives and communicates consistent messages in all
and assists in completing reports that may include but are not limited to
identification of utilization trends, overall quality of the health care of the
care managed population, etc.Responsible
for the monitoring of weekly audits to ascertain that process standards are met
and successful outcomes are achieved.Facilitate
care coordination, care management interaction and problem solving through
regular team meetings for communication and feedback, staff training and
development, sharing of program results, and collaborative problem solving.Establishes
working relationship with referral sources.Assesses
patient specific information related to level of function and individual needs.
the use of interviewing skills that include the professional judgment to probe
as necessary to uncover underlying concerns of the client.Plans
and establishes treatment goals that meet client health care needs as
identified through the assessment process.Identifies
and implements available, appropriate and cost effective treatment modalities
based on the plan. The plan is action oriented and time specific.Knows
average benchmarks for duration of services for disease treatment.Communicates
case objectives and sets goals for services providers. Plans
and participates in data gathering procedures.Assesses
clinical evaluations and co-ordinates all aspects of treatment options to meet
high-risk cases and possibility of complication. Considers and applies
principles of human behavior, family/care giver dynamics, human development and
disability into the care management process. Shares
and reports legal and professional issues pertaining to confidentiality.Acts
as an advocate for the individual’s health care needs.Assesses
and addresses specific disease process issues.Applies
regulatory scope of practice to home care providers.Continuously
monitors status and impact of care management and adjusts plan
accordingly. Evaluates
the client need for medically necessary services at intervals, determines the
effectiveness in reaching desired outcome and goals.Modifies
the plan of care as indicated.Evaluates
the quality of services performed by providers.· Works closely with all identified
members of the team including physician, nurse, provider, insurer, and client throughout the
and maintains a satisfactory level of perceived client satisfaction.Interpret
insurance coverage, exclusions and reimbursement conditions.Utilizes
cost containment strategies that maximize access to funding.Evaluates,
negotiates and plans for the cost of care options.Documents
all care management services rendered.Utilizes
planning and goals development techniques.Maintains
awareness of federal legislation effecting care management services.Establishes
client support systems while utilizing available resources and services.Utilizes
appropriate community resources and services to achieve optimal outcomes while
reducing financial exposure.Provide
exceptional customer service to all internal and external contacts.

Demonstrated interviewing skills which include the professional judgment to
probe as necessary to uncover underlying concerns of the applicant.

(B) Demonstrated ability to establish and
maintain empathic relationships;

(C) Experience in conducting social and health

Knowledge of human behavior, family/caregiver dynamics, human development and

(E) Awareness of community resources and

(F) The ability to understand and apply complex
service reimbursement issues.

The ability to evaluate, negotiate and plan for the costs of care options.


for assisting Care Managers and Care Contact Coordinators in problem solving
and managing challenging scenarios on a day-to-day basis. Interacts with supervisor in problem solving
activities, as required.


perform this job successfully, an individual must be able to perform each
essential duty satisfactorily. The
requirements listed below are representative of the knowledge, skill, and/or
ability required. Reasonable
accommodations may be made to enable individuals with disabilities to perform
the essential functions. Basic knowledge
of Windows, Excel and Word

management supervisors shall meet all the qualifications of a care manager plus
have demonstrated supervisory ability, and at least one year of specific
experience in conducting assessments, developing care plans, and monitoring
home and community based services


possess a current RN license in the state of residence. A minimum of three years relevant nursing
experience in clinical experience in a hospital/facility/home care setting,
preferred. A minimum of 3+ year’s
previous supervisory experience that may include Quality Assurance, Utilization
Management, and/or Care/Disease Management. An Associate or Bachelor’s Degree
in nursing, health and gerontology or a related field. Care Management Supervisor shall have the
following additional qualifications: (a)
demonstrates ability to establish and maintain empathetic relationships; (b)
experience in conducting social and health assessments; (c) knowledge of human
behavior, family/caregiver dynamics, human development and disability; (d)
awareness of community resources and services; (e) must demonstrate effective
supervisory ability, and at least one year of specific experience in conducting
assessments, developing care plans, and monitoring home and community-based
services, and (f) computer literacy.


to read, write and comprehend English. Ability to analyze, interpret general
business periodicals, professional journals, technical procedures, or
governmental regulations. Ability to
write reports, business correspondence, and procedure manuals. Ability to effectively present information
and respond to questions from groups of managers, clients, customers, and the
general public.


to calculate figures and amounts such as discounts, interest, commissions,
proportions, percentages, area, circumference, and volume. Ability to apply concepts of basic algebra
and geometry.


to solve practical problems and deal with a variety of concrete variables in
situations where only limited standardization exists. Ability to interpret a variety of
instructions furnished in written oral, diagram, or schedule form.


license required.

degree and/or CCM certification a plus.


physical demands described here are representative of those that must be met by
an employee to successfully perform the essential functions of this job.
Reasonable accommodations may be made to enable individuals with disabilities
to perform the essential functions.

performing the duties of this job, the employee is frequently required to sit;
use hands to finger, handle, or feel; and talk or hear. The employee is occasionally required to
stand; walk; reach with hands and arms; climb or balance; and stoop, kneel,
crouch, or crawl. The employee must
occasionally lift and/or move up to 10 pounds.
Specific vision abilities required by this job include close vision, distance
vision, color vision, and ability to adjust focus.


work environment characteristics described here are representative of those an
employee encounters while performing the essential functions of this job.
Reasonable accommodations may be made to enable individuals with disabilities
to perform the essential functions.

setting or work from home setting, as determined by department management.