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Job Description

• ASSESSMENT 1.1 Accurately gathers and interprets information obtained to identify members suitable for effective case management intervention. 1.2 Competently uses assessment skills to identify physical, psychosocial, and environmental health care needs of the member. 1.3 Educates the member and appropriate ancillary personnel about the health care needs, safety issues and benefits. 1.4 Assess and identify appropriate resource utilization, level of care, and treatment options to develop a plan of care that will impact quality outcomes in a cost-effective manner.
• PLANNING & LEADERSHIP 2.1 Collaborates with the member and a multi-disciplinary healthcare team to promote quality care, prevent complication, and improve outcomes. 2.2 Works with the member to develop a plan of care that will avoid duplication and/or fragmentation of services. 2.3 Ensures provision of appropriate use of ancillary services. 2.4 Provides guidance and direction initiating and implementing modifications to the plan of care as needed.
• IMPLEMENTATION & FACILITATION 3.1 Efficiently documents assessments, clinical findings, multiple and complex needs, plans of treatment, and progress toward goals. 3.2 Keeps accurate records and submits them in a timely manner. 3.3 Accurately identifies and facilitates the appropriate level of care
• MONITORING & EVALUATION 4.1 Monitors the member’s response to healthcare services and products delivered. 4.2 Regularly determines the problems, milestones, and if the goals of the plan of care are being achieved or if there is a need for revision or adjustment of the plan of care. 4.3 Monitors, evaluates and coordinates referrals from multiple sources.
• COMMUNICATION & COORDINATION 5.1 Actively promotes frequent communication between all team members, providers, members and their families to enable a smooth transition from one level of care to another. 5.2 Shares awareness of community resources, support systems, and benefits available. 5.3 Maintains regular communication with all providers delivering care, services, and product to the member to assure quality care is provided.
• Departmental • Oversees the daily functioning of the case and disease management teams. • Ensures compliance to case and disease management and processes by assuring proper staff training occurs, conducting and/or reviewing quality assurance and audit results, and takes appropriate action. • Plans, organizes, and implements collection of data and preparation of reports that support case and disease management activities. • Develops and maintains expertise in regulatory and accrediting requirements as they pertain to the case and disease management functions. Ensures policies and procedures are current and that staff is trained accordingly. • Develops policies, procedures, and workflows to support case and disease management. • Works with the managers in the department to identify barriers to smooth transition of workflow and cases between staff members. • Identifies opportunities for improvement and develops solutions. • Prioritizes work effectively and provides results in a timely manner. • Participates in the annual review of Health Management policies and procedures. • Maintains current knowledge of all departmental activities. • Keeps the Sr. Manager of Case and Disease Management and the AVP of Health Management informed as needed/appropriate.
• Leadership • Provides leadership and coaching to case and disease management team members. • Is responsible for hiring, developing, and developing, and evaluating the staff of the case and disease management teams. • Collaborates with the Senior manager of Case and Disease Management and the AVP of Health Management to develop and implement health management programs that will allow Priority Health achieve its core purpose. • Provides input into the development, implementation and evaluation of departmental goals and objectives. • Ensures an orientation plan is in place for each new employee. • Systematically evaluates the quality and effectiveness of staff performance, analyzing appropriate data and information to identify areas of improvement. • Understands and holds staff accountable to all accrediting and regulatory expectations pertaining to case and disease management. • Oversees and/or participates in the orientation and training of new-hire employees. • Ensures timely and accurate distribution of communications. • Demonstrates self-directed, self-motivated, responsible behavior. • Assumes personal responsibility for professional growth and continuing education. • Maintains certification in specialized clinical area (ie, CDE) in order to o provide expertise to the case management team. o Represent Priority Health at external meetings as a clinical expert • Develops and maintains expertise in relation to Health Management compliance with regulatory and accrediting bodies as assigned, including NCQA, Department of Labor, CMS, and MDCH. • In conjunction with the Sr. Manager of Case and Disease management, ensures compliance to internal and external standards by assuring proper staff training and reviewing quality assurance and audit results, and collaborating with other members of the management team as needed. • Plans, organizes, and implements collection of data and preparation of reports that support departmental activities. • Leads, or participates in, projects and process improvement activities as assigned.
• Corporate • Participates in interdepartmental committees and/or workgroups that are pertinent to areas of responsibility. • Effectively intercede with other employees/departments to resolve concerns related to staff or process. • Assists Provider Services, Customer Service and the Marketing Department in their efforts to communicate case and disease management policies and procedures to providers, employers, and members.

• Required Bachelor's Degree or equivalent in nursing or a health related field; Master's of Social Work (for candidates/incumbents with a social work license)
• 1 year of relevant experience Skills, knowledge, abilities typically gained through 1+ year of related experience
• 7 years of relevant experience including a minimum of three years managed care experience. Required
• 1 year of relevant experience Supervisory Required
• Leadership Preferred
• Strong knowledge of managed health care clinical programs and reporting. Preferred
• LIC-Registered Nurse (RN) - STATE_MI State of Michigan preferred Or
• LIC-License Practical Nursing (LPN) - STATE_MI State of Michigan preferred Or
• LIC-Master Social Worker (MSW-Master) - STATE_MI State of Michigan preferred Or
• LIC-Master Soc Work LTD - STATE_MI State of Michigan preferred

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Spectrum Health requires all team members to receive the COVID-19 vaccinations subject to certain exclusions based on the team member’s job category. Spectrum Health is committed to granting reasonable accommodations in accordance with applicable laws.

Accommodation Notice: If you are a qualified individual with a disability, you may request a reasonable accommodation in Spectrum Health's application process. Contact us at 616-486-SHHR (7447).

Spectrum Health grants equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status, height, weight, sexual orientation, veteran status, or any other legally protected

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