POSITION SUMMARY

The Assistant Manager, Medical Management (MM) provides day-to-day operational leadership for Utilization Management (UM) and Care Management (CM). Community Health Options is continuously striving for the Quadruple Aim (high quality, superb Member and provider experience, and lowering the overall cost of healthcare).

The incumbent has strong working knowledge of nationally recognized clinical standards of care (e.g., MCG®), utilization management, care management, complex case management, care coordination, claims processing, and cost containment strategies. This leader provides oversight of daily operations to ensure efficient and effective operations that promote cost-effective, high-quality outcomes across the continuum of care.

The Assistant Manager, MM leads an interdisciplinary team of healthcare professionals who work collaboratively to provide integrated medical and behavioral healthcare. The incumbent leads the team in balancing advocacy for the individual (based on benefit design) with stewardship for the entire membership while ensuring adherence to the National Committee for Quality Assurance (NCQA) standards, and all applicable State and Federal regulations.

Work from home flexibility is available based on operational need and supervisor approval. Local and occasional business travel may be required.

RESPONSIBILITIES

• In collaboration with the Senior Manager of Medical Management, the Assistant Manager oversees effective and efficient day-to-day operations of Health Options MM Program in accordance with NCQA Standards, State and Federal regulations.
• Promotes a culture of trust, transparency, and accountability balanced with advocacy for individuals and stewardship for Health Options membership as a whole.
• Maintains strong working knowledge of Health Plan benefits and network design and facilitates clinical claims review based on Member eligibility, benefit coverage and medical necessity.
• Supports Senior Manager in ensuring the team has sufficient resources and information to facilitate consistent adherence to established policies and procedures that align with Health Plan and self-funded product benefit design.
• Supports Senior Manager in overseeing referrals, timely completion of work, and tracking services to promote Members receiving high quality, cost-effective care with the right provider, in the right setting, at the right level of care at the right time.
• Supports team in navigating complex clinical presentations leveraging care management and utilization management principles.
• Supports Senior Manager in ensuring team consistently participates in quality improvement initiatives and work efforts to meet division/organization goals.
• Supports Senior Manager and closely collaborates with internal stakeholders across functional areas to promote exemplary Member and Provider customer service through effective communication and workflow strategies.
• Contributes to review of overall population utilization trends and identifies outliers for further analysis and intervention, when applicable.
• Supports Senior Manager in compiling reports for NCQA, regulators, compliance, auditors, and applicable committees upon request.
• Develops and maintains super user expertise of documentation platform to support daily operations and system upgrades.
• Maintains expertise and manages reporting tools to inform case assignment allocation and provides operation reports and metrics for same.
• Monitors individual team member performance and provides mentoring and coaching as needed to promote consistent adherence to standards and shared ownership of quality outcomes.
• Facilitates team access to professional development opportunities that align with organizational goals and priorities.
• Maintains confidentiality in all aspects of Member, Health Options’ people and proprietary information.

KEY COMPETENCIES

Leaders within Health Options are expected to work with integrity, humility, strategic vision, curiosity, and discipline. Incumbents must be self-motivated, highly effective, and compassionate communicators, who effectively lead people, manage work processes, and actively engage in continuous process improvement.

DIVERSITY, EQUITY, AND INCLUSION STATEMENT

Community Health Options is committed to fostering, cultivating, and preserving a culture of diversity, equity, and inclusion (DEI). Our human capital is the single most valuable asset we have. The collective sum of individual differences, life experiences, knowledge, inventiveness, innovation, self-expression, unique capabilities, and talent our employees invest in their work represents a significant part of not only our culture, but our reputation and achievement as well. Community Health Options DEI initiatives are applicable, but not limited to, our practices and policies on recruitment and selection; compensation and benefits; professional development, and training; promotions; transfers; social and recreational programs, and the ongoing development of a work environment built upon the premise of DEI, which encourages and enforces:

• Respectful, open communication and cooperation between all employees.
• Teamwork and participation, encouraging the representation of all groups and employee perspectives.
• Balanced approach to work culture through flexible schedules to accommodate varying needs of our people.
• Employer and employee contributions to the communities we serve to promote a greater understanding and respect for each other.

QUALIFICATIONS

• Bachelor's or Associate's Degree in Nursing
• Active and unrestricted Compact or Maine clinical license.
• Minimum of 2-3 years of Health Plan Medical Management experience.
• Leadership experience with working knowledge of human resource principles that promote a positive working environment and adherence to applicable regulatory requirements.
• Ability to adapt and be nimble to effectively problem-solve complex, multifaceted, and/or emotionally charged situations.
• Advanced Skills in Microsoft Products and adaptability to electronic documentation system.
• Excellent communication, writing, analytical and problem-solving skills.