Somos Your Health, LLC
Full Job Description
Job Description:
The Head of Case Management, under the direction of the Chief Medical Officer plans, organizes, implements, directs, and coordinates activities related to case management for our high-risk members. The Head of Case Management is responsible for providing oversight, direction, and strategic planning for the operations of our member high-risk case management programs. Develop innovative strategies and tactics for engaging the high-risk members, their providers, and the network delivery system to ensure top-quality care is delivered to our patients. The Head Case Management will work closely with the clinical quality team, clinical quality data and analytics team, networking, and SOMOS leadership to ensure that all high-risk members receive appropriate, high-quality healthcare.
Role Responsibilities
Oversees the use of member risk-stratification analytics and member profile care management tools
Creates workflows and processes that relate to managing high-risk members ensuring that all high-risk members receive appropriate, high-quality health care.
Oversees the training of the Case Management team
Manages the Case Management team by monitoring their activities and productivity.
Assists in the development of Quality Standards and metrics to measure the ongoing activities within the assigned process area.
Tracks and trends Case Management team outcome results include but are not limited to:
o Member Enrollment
o Member Engagement
o Member Program completion
o Average Case duration in CM
o Member caseloads
o Impact on overall cost (PMPM), In-Patient Admissions/Readmission rates, ED visits rates, and Quality measures such as HEDIS & STARS
Develop strategies to conduct a review of industry-wide changes for engaging providers that ensure that the SOMOS Case Management program is aligned with CMS, NCQA, NYS Medicaid, Medicare Stars, and other health plans’ data-driven approach.
Enforces and promotes Quality Improvement process frameworks, procedures, policies, and standards.
Evaluate documentation to ensure completeness, accuracy, and compliance with Case Management standards.
Participates in the development of appropriately defined dashboards to report on the risks and accomplishments of assigned initiative or process area.
Recommends and implements new technologies, methodologies, processes, and procedures to support short-and long-term department goals.
Develops and maintains professional relationships with health system leadership stakeholders.
Competencies and Qualifications
Bachelor’s degree in Nursing is required.
Master’s degree in healthcare, business, or healthcare preferred
Current/active unrestricted New York State licensed Registered Nurse
5+ years of experience in a managed care setting preferred
Outstanding leadership, analytical, negotiation, and conflict resolution skills
Strong verbal and written communication skills required
Ability to interface with all levels of employees About SOMOS Innovation, LLC: SOMOS Innovation, LLC is the organization that has been built to deliver on a simple promise – to provide the administrative infrastructure to enable our physicians to deliver high-quality community healthcare to our vulnerable Medicaid and Medicare patients in a culturally appropriate manner. The physician leaders of Corinthian Medical, Excelsior Medical, Balance Medical, SOMOS Your Health, SOMOS, and Eastern Chinese IPA have seen that to succeed in a VBP world the IPAs and physicians must be supported by an integrated management services organization. The MSO must deliver a portfolio of managed care contracts and the infrastructure to manage the financial risk attached to those contracts. The MSO must deliver administrative simplification for the PCPs and IPAs that generates more patient time and enables the PCPs to deliver the right care, at the right time in the right setting. The MSO must deliver clinical innovation that moves “population health” from theory to practice. The following grid highlights the functionality delivered to each of the IPAs.
