Lead Care Manager

This is a fully remote position, open to applicants in United States.

📋 Description

• Engage in activities pertaining to the development, execution, supervision, and delegation of care management programs.

• Aid in assuring compliance with CMS SNP Model of Care (MOC) standards, NCQA criteria, and Medicare Advantage regulations.

• Contribute to the formulation and execution of policies and procedures related to the Care Management process.

• Support the monitoring of performance metrics, productivity, and ensuring adequate staff coverage to fulfill departmental needs.

• Develop, implement, and assess educational strategies for staff members.

• Maintain an understanding of the requirements set by regulatory and compliance organizations.

• Mentor new Care Managers and assist in their training.

• Offer support and coaching to Care Managers and other members of the clinical team.

• Conduct data collection and analysis of trends to identify areas for improvement and strategies for enhancing practices within the Care Management team.

• Handle escalated calls or provide support to the Care Manager team during peak periods.

• Aid in quarterly reporting of delegated case management processes to fulfill accreditation standards.

• Assist in the submission of necessary documents and policies during the application process to the accrediting body.

• Provide clinical, procedural, or interpretational assistance.

• Capable of presenting complex concepts and data to a diverse range of stakeholders, from frontline staff to executive-level leaders.

• Establish and maintain cooperative and positive working relationships with key stakeholders throughout the organization.

• Take part in the Interdisciplinary Care Team (ICT) alongside the SNP CM team, PCP, and beneficiaries/caregivers.

• Assist in utilizing Peak Health’s analytics tools to track HRA timeliness, care plan compliance, ICT effectiveness, utilization patterns, and quality outcomes.

• Act as a key liaison between SNP Care Management, Peak Health providers, pharmacy, behavioral health partners, and community organizations.

• Support the escalation and review of high-risk, high-need member cases to ensure suitable interventions, community resource connections, and adjustments to care plans.

• Collaborate with Peak’s Quality Management and Compliance teams to enhance Stars ratings, HEDIS performance, coordinate utilization management, and ensure audit readiness.

• Assist in the escalation and review of high-risk, high-need member cases to guarantee appropriate interventions, connections to community resources, and modifications to care plans.

⛳️ Requirements

• Possession of a current Registered Nurse license issued by the state where services will be delivered, or a current multi-state Registered Nurse license through the enhanced Nurse Licensure Compact (eNLC).

• A minimum of five (5) years of clinical experience in healthcare.

• At least two (2) years of experience in Care Management, Case Management, or Population Health.

• A Bachelor’s Degree in Nursing OR an Associate of Science in Nursing Degree (ASN) or a diploma.

• Experience managing Medicare, Medicaid, and/or SNP populations.

• A minimum of one (1) year of experience in SNP Care Management.

🏝️ Benefits

• Some travel may be necessary for offsite meetings.