Job Description

POSITION SUMMARY:

The Enhanced Care Management (ECM) and Community Supports (CS) Manager provides leadership related to the growth and sustainability of CalAIM’s (California Advancing and Innovating Medi-Cal) ECM and CS programs by collaborating with Providers, the County, various community-based organizations, and internal stakeholders to deliver a robust set of integrated supports for those members who require complex care management interventions.

COMPLIANCE WITH REGULATIONS:

Works closely with all departments necessary to ensure that processes, programs and services are accomplished in a timely and efficient manner in accordance with CHG policies and procedures and in compliance with applicable state and federal regulations including Department of Healthcare Services (DHCS).

RESPONSIBILITIES

• Oversees and monitors the ECM/CS department’s daily operations along with all staff.
• Engages regularly with CHG leadership to refine or modify ECM and CS to achieve objectives and meet Department of Healthcare Services (DHCS) requirements. ECM/CS Manager will ensure compliance with all regulatory requirements related to ECM/CS services.
• Supports CHG’s Healthcare Services Department in tandem with the Contracting Department in the expansion of the ECM/CS provider network; conducts complex research while vetting potential providers.
• Onboard and trains newly contracted providers on core services, reporting, compliance measures, and quality improvement areas.
• Facilitates thorough trainings on the navigation and functionality of the ECM/CS provider portal, where providers are required to document clinical and non-clinical interactions.
• Provides oversight, monitoring, and regular communications with ECM/CS providers and internal departments to ensure core service components are delivered to members.
• Provides oversight, monitoring and regular communication to complete all regulatory reporting requirements associated with ECM, CS, Incentive Payment Program (IPP) and Housing & Homelessness Incentive Program (HHIP).

• Monitors and assesses the ECM/CS Team’s requests for assistance from the informatics systems (IS) department for things such as report modifications, new requests for reports, provider portal glitches, data or system errors, etc...
• Provides the IS team with updated materials and approved changes to provide ongoing maintenance of the provider portal to help with streamlining the provider workflows and data collection process, following all regulatory requirements.
• Works closely with IS’ Senior Business Analyst to execute ECM/CS provider portal enhancements projects such as automations and gaining special administrative access.
• Leads the ECM/CS Team in testing changes or enhancements made to the ECM/CS provider portal, consolidates feedback and shares with IS prior to production deployment.
• Trains providers on changes and enhancements made to the ECM/CS provider portal as needed.
• Strategically plans and implements methods to measure program success such as evaluating health outcome improvements and a reduction in utilization costs.
• Strategically plans and implements new practices to assist with program expansion goals including but not limited to the following activities: community outreach and networking, marketing, redistribution of provider assignments as needed, etc…
• Drafts, recommends and implements administrative policies and departmental procedures related to the operation of ECM and CS.
• Supports the ECM/CS Team, ancillary departments and providers by creating and maintaining best practice and/or user guides to support efficient and streamlined processes.
• Trains internal stakeholders to ensure that ECM/CS providers are aware of ECM/CS’ core service components and delivery strategies.
• Strategizes process improvements to ancillary departments impacted by the growth of ECM/CS such as Member Services and Claims Department.
• Tracks and monitors ECM/CS submission deadlines to DHCS and ensures that reports are complete, accurate and submitted in a timely manner.
• Remains current with ECM’s populations of focus criteria or program timelines following DHCS direction and relays important updates to impacted departments.
• Works closely with IS’ data analytics team to ensure reports accurately capture ECM/CS data to remain in compliance with DHCS’ regulations and reporting requirements.
• Oversees and develops ECM provider reporting and recognizing needed process improvement efforts, in collaboration with the Quality Improvement and Health Education Departments.
• Works with the Compliance Department to monitor regulatory, legislative, and legal changes related to ECM and CS functions and ensure compliance with the same.
• Responsible for submission of CalAIM grant funding progress reports to DHCS to ensure milestones are being met.
• Provides staff support to CHG operational and clinical committees, as needed.
• Writes narrative and statistical reports and makes presentations related to applicable ECM and CS topics.
• Oversees the preparation, maintenance, and tracking of records, information, and related documents.
• Oversees the review and processing of complex ECM and CS referrals to ensure eligibility requirements are met.
• Monitors providers’ utilization of ECM/CS services and develops ways to close the loop on referrals.
• Provides updates to CHG leadership, makes presentations, supports, and training end-users, and develops related materials. Stays informed of current best practices and new developments in the field and ensure staff does the same.
• Regularly provides ECM/CS data to CHG leadership such as to the Senior Health Care Services Director, Chief Corporate Counsel, Chief Operating Officer, etc…
• Provides written guidance and/or talking points to CHG leadership on ECM/CS statuses as needed.
• Provides guidance to ECM auditing team to assist with special monitoring projects dependent upon programmatic needs.
• Solicits and reviews clinical and non-clinical Member documentation from providers for auditing purposes and communicates any pending follow-up action items to providers and CHG leadership as needed.
• Researches and communicates ECM and CS regulatory, legal, and program updates and changes to internal and external stakeholders.
• This position requires occasional travel within the San Diego County area.

Experience/Skills:

Knowledge, Skills, and Abilities

• Working knowledge of the community-based organizations and medical office practices and processes, including those related to workflow design and improving the patient/consumer experience.
• Working knowledge of the principles and practices of community-based service delivery to at-risk populations.
• Working knowledge of the principles and practices of case management.
• Working knowledge of and proficiency in research, analysis, and reporting methods.
• Working knowledge of the principles and practices of program and project management.
• Knowledge of managed care principles, CPT, ICD-9 & 10, HCPCS coding.
• Knowledge of Medi-Cal and related policy and benefits-related Title 22 regulations.
• Some knowledge of the principles and practices of utilization management.
• Some knowledge of electronic medical record systems.
• Some knowledge of the principles and practices of statistical analysis.
• Excellent resilience and organizational, interpersonal, and time management skills.
• Ability to communicate effectively verbally and in writing; exceptional telephone and customer service skills; ability to establish effective working relationships with physicians and medical professionals; ability to organize work effectively, determine priorities, and work well independently.

Education:

• Bachelor's degree in Healthcare Administration, Nursing, Behavioral Health, Social Science or a related field and a minimum of six years of professional-level outpatient medical, community health service delivery, behavioral practice management, or related healthcare experience, including some lead or supervisory responsibility (a Master's degree may substitute for two years of the required experience); or an equivalent combination of education and experience may be qualifying.

Desirable Qualifications

• At least one year of work experience in a managed care environment.
• At least three years of paid supervisory experience.
• Working knowledge of Medi-Cal, Medicaid, Medicare, entitlement programs, and related regulations.
• Some knowledge of State and Federal legislative processes.

Physical Requirements:

• Prolonged periods of sitting at a desk; intermittent standing, walking, bending, stooping, lifting ten lb. or less.
• It may be necessary to work and attend meetings outside of the facility or regular business hours.

The above statements describe the general nature and level of work being performed. They are not intended to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified.

Community Health Group is an equal opportunity employer committed to fair and equitable treatment for all employees. We prohibit discrimination and harassment based on any protected characteristic as outlined by federal, state, or local laws. This policy applies to all employment practices within our organization, including hiring, recruiting, promotion, termination, layoff, recall, leave of absence, compensation, benefits, and training. Community Health Group makes hiring decisions based solely on qualifications, merit, and business needs at the time.

Job Tags

Work experience placement, Local area,

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