Manager of Care Management- Pediatric Complex Care

It's an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.

Job Summary:

The Manager of Care Management-Pediatric Complex Care is responsible for the daily operations of the Special Kids Special Care (SKSC) Care Management team. This includes hiring, scheduling, coaching, staff development and performance evaluation. The manager provides oversight and guidance to ensure staff engage effectively with pediatric patients and families, focusing on improving health outcomes, enhancing the patient and family experience, and reducing costs.

This role ensures that care plans are individualized, patient centered and developed through a strengths-based approach that identifies barriers and promotes coordination of care. The Manager serves as a working leader, directly supporting care management for patients with complex pediatric needs and will develop, monitor and revise workflow operations to ensure individual and team effectiveness. The manager will recommend and assist in the development and implementation of policies and procedures that integrate state, national accreditation regulations to ensure compliance with regulatory and accreditation standards.

Strong interpersonal and engagement skills, as well as the ability to work both independently and collaboratively, are essential for success in this role.

Our Investment in You:

* Full-time remote work

* Competitive salaries

* Excellent benefits

Key Functions/Responsibilities:

• Supports programs and clinical best practices with the objective of improving health outcomes, preventing hospital readmissions, improving member safety and reducing medical errors, and promoting health and wellness activities, where appropriate. Engages in functions of health information technology development that enhances or maintains activities associated with QI initiatives, accreditation, and monitoring, measuring or reporting clinical effectiveness and outcomes.
• This position will act as the key medical care manager for pediatric patients with medical and psychosocial complexity. Working as a part of an interdisciplinary team serving culturally diverse families with chronic illnesses, special needs, and a variety of neurodevelopmental and related diagnoses, the individual is responsible for outreach to families, meeting with families during clinic sessions, and making home visits in the community. Using the information gathered from the family and the medical team, the care manager is responsible for developing and implementing an individualized, patient-centered care plan. Implementation of the care plan may involve: working with partnering organizations to ensure the child is receiving necessary services, assisting families in interactions with school system and community agencies, and acting as a liaison with the child's insurance plan.
• Ability to execute core care management duties
• Comprehensive assessment: bio-psycho-social-spiritual
• Collaboration with patient and care team to develop patient-centered care plan, with particular focus on chronic disease management, social determinants, transitions of care and advanced care planning.
• Collaboration with program stakeholders and community partners.
• Coordinates with health care providers to make sure needs are being met.
• S/he will also work with partnering organizations to make sure that children have all needed medical services
• The individual is responsible for working with patients to identify strengths and barriers and to develop an individualized, patient-centered care plan. Excellent interpersonal skills, clinical expertise in pediatrics and the ability to work both independently and collaboratively are key requirements of the job
• Has knowledge of common chronic medical conditions presented in the population served and is able to:
• Educate the patient and their caregivers on their conditions and medications, and build their self-management skills;
• Use motivational interviewing to promote behavioral change;
• Assess, triage, and rapidly respond to clinical changes that could lead to the need for emergency services if not intervened upon.
• Facilitates interdisciplinary consultation on patient's behalf through participation in clinical review team (CRT) meetings
• The individual will arrange for case conferences as needed, involving school, day care and early intervention services providers as appropriate.
• Complies with established metrics for performance and adheres to documentation and work flow standards
• Maintains HIPAA standards and confidentiality of protected health information.
• Adheres to departmental/organizational policies and procedures.
• Managing team calendar including vacation schedule, holiday schedule and time cards.
• Offer feedback and goal setting for staff through regular performance reviews.
• Monitor case inventory and team members' workload and adjusts as necessary.
• Maintain open and frequent contact with team members including facilitation of CM team meetings.
• Assist in identifying and hiring of new staff as needed.
• Oversee orientation of new staff
• Work with the clinical trainer to develop appropriate training materials and programs for the team.
• Supports CM initiatives through communication strategies, team leadership, facilitation and recommendations.
• Responds to staff issues and concerns and escalates to management as appropriate.
• If staff performance is below expectations will identify opportunities for improvement with leadership and implement interventions to address opportunities.
• Triages patient concerns and queries.
• Reviews, verifies and retrieves data.
• Represent SKSC CMs in meetings with WellSense to plan for the future needs of this population and implementation of changes to the program as needed.
• Work closely with all appropriate internal departments to resolve complex issues related to the medical and social case management needs of members.
• In collaboration with Public Partnerships and medical director, represent the Care Managers with external contacts as needed (e.g., EOHHS, DCF).
• Assist with and participate in the planning, development and implementation of CM department specific and cross functional projects.
• Assists with determining workflows/processes for CM team.
• Maintain Policies and Standard Operating Procedures that are consistent with SKSC's contract requirements
• Perform other duties as assigned or as needed.

Supervision Exercised:

• Manages 6-7 clinical and non-clinical staff.

Supervision Received:

• Regularly schedule meetings with Director and/or Vice President of Care Management

Qualifications:

Education Required:

• Bachelor's degree in nursing or Associate's degree in Nursing

Education Preferred:

• CCM certification
• Bachelors or Master's Degree in Nursing or related field

Experience Required:

• A minimum of four years of pediatric clinical experience is required, with care management experience preferred; candidate should have demonstrated leadership and supervisory experience and potential.

Experience Preferred/Desirable:

• Home care
• Motivational interviewing
• Primary care
• Care management
• Clinical experience working with pediatric patients with multiple complex health issues

Required Licensure, Certification or Conditions of Employment:

• Successful completion of pre-employment background check
• Licensed to practice professional nursing as a Registered Nurse or Nurse Practitioner in the Commonwealth of Massachusetts.
• Certification in NCM/CCM preferred
• Transportation

Competencies, Skills, and Attributes:

• Understands health care delivery to diverse patient populations
• Demonstrated commitment to excellent customer service
• Intermediate skill level with Microsoft Word, Excel, Visio and PowerPoint.
• Effective collaborative and proven process improvement skills
• Strong oral and written communication skills; ability to interact within all levels of the organization as well as with external contacts

Working Conditions and Physical Effort:

• Work is normally performed in a remote home office work environment and in members' homes.
• Limited physical effort required.
• Must be able to travel regularly to conduct member home visits.

Compensation Range

$86,500- $125,500

This range offers an estimate based on the minimum job qualifications. However, our approach to determining base pay is comprehensive, and a broad range of factors is considered when making an offer. This includes education, experience, skills, and certifications/licensure as they directly relate to position requirements; as well as business/organizational needs, internal equity, and market-competitiveness. In addition, WellSense offers generous total compensation that includes, but is not limited to, benefits (medical, dental, vision, pharmacy), merit increases, Flexible Spending Accounts, 403(b) savings matches, paid time off, career advancement opportunities, and resources to support employee and family wellbeing.

Note: This range is based on Boston-area data, and is subject to modification based on geographic location.

About WellSense

WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances. WellSense is committed to the diversity and inclusion of staff and their members.

Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status. WellSense participates in the E-Verify program to electronically verify the employment eligibility of newly hired employees