Job #: 2195
Title: Manager of Children Special Services
Under the direction of the Medically Fragile Children Medical Director, the Manger of the Children’s Special Services (MCS) serves as the clinical team leader and the Medically Fragile Children Liaison. The incumbent manages day to day activities of the Children’s Special Services clinical team. This is accomplished through hands-on, participatory management where all aspects of day to day utilization and case management operations are supervised and feedback is shared with the leadership team for the purpose of meeting program goals and the implementation of continuous quality improvement strategies.
The MCS ensures high touch coordination for all Medically Fragile Children. This is accomplished by day to day supervision of the Plan’s MCMs, ensuring that the quarterly follow up calls with the Health Home care coordinators are done on a timely basis. The MCS oversees the utilization of necessary services to support children.
The MCS ensures that the authorization of HCBS and the monthly and quarterly follow up assessments are conducted in an appropriate and timely fashion.
The MCS facilitates the successful execution of the Integrated Clinical Management program by providing day to day supervision and applying problem solving skills to ensure the delivery of member-centered case management, improved access to community resources and improvement of overall health status of members.
· Serves as the Medically Fragile Children Liaison
· Serves as a lead for the clinical team.
· Supervises all the UM and CM activities of the Children’s Special Services unit.
· Responsible for high touch coordination for Medically Fragile Children.
· Ensures the provision of clinical services, Health Home coordination and HCBS services to foster children who are MetroPlus’ members.
· Works with Foster Children Liaison (FCL) to monitor timely access and appropriate services for B2H Medically Fragile Children.
· Responsible for compliance with the UM requirements for the medically fragile population set forth by the “Office of Health Insurance Programs Principles for Medically Fragile Children.
· Helps to generate reports of trends in grievances, appeals and denial requested by medically fragile children.
· Oversees the review and the approvals of Plans of Care and the authorizations of HCBS services.
· Oversees the authorization of clinical services and DMEs requested by medically fragile children.
· Ensures the monitoring of care coordination, CANS-NY assessments and HCBS services provided by Health Homes and HCBS providers.
· Works with the FCL to ensure continuation of care for foster children disenrolling from the plan and/or leaving foster care.
· Provide clinical guidance and supervision to assigned UM-CM and Case Management Associates in order to promote efficient and effective delivery of clinical management services.
· Supervise the entire case management workflow including case selection, interventions and goal setting, follow-up/follow-through activities, documentation and escalations.
· Ensure clinical management activities are conducted in a safe, efficient and effective manner to promote continuity and quality of care.
· Review, develop and modify day to day workflows to ensure timely authorizations of HCBS services and other needed medical services.
· Perform ongoing quality review of cases to ensure accuracy and compliance.
· Evaluate and document staff performance; coach staff to improve both quality and quantity of skills attaining optimal performance.
· Utilize data to track, trend and report productivity and outcome measures; work with the management team to implement necessary improvement strategies.
· Resolve issues and mitigate conflict encountered during daily operations; appropriately escalate issues to Director of Children Special Services.
· Identify and report potential risk, operational opportunities and barriers encountered in the day to day operations, proactively share with the leadership team.
· Conduct monthly audits for the purpose of departmental/organizational reporting and providing formal feedback to clinical and managerial staff.
· Create and submit operational weekly/monthly/quarterly reports.
· Work with the leadership team to develop and implement ongoing training and development efforts.
· Actively participate in staff training and meetings.
· Encourage regular communication and inform staff of relevant departmental and organizational updates.
· Employ critical thinking and judgment when dealing with unplanned issues.
· Develop and maintain collaborative relationships with Health Home care coordinators, HCBS and clinical providers, facility staff and community resources.
· Comply with orientation requirements, annual and other mandatory trainings, organizational and departmental policies and procedures.
· Maintain professional competencies as a Team Leader.
· Perform other duties as assigned by the Director of Children’s Special Services and the Senior Director of Case Management and/Designee.
· Bachelor’s Degree required, Masters preferred
· Clinical background: Registered Nurse licensure required
· Minimum of 5 years-experience as a pediatric nurse, experience with Care at Home/ Medically Fragile Children strongly preferred.
· An equivalent combination of training, educational background and experience in related fields and educational disciplines. A minimum of 3 years of UM or CM experience in a health care and/or Managed Care setting required.
· Minimum of 2 years managerial/leadership experience in a Managed Care and/or health care setting required.
· Proficiency with computers navigating in multiple systems and web based applications
· Confident, autonomous, solution driven, detail oriented, high standards of excellence, nonjudgmental, diplomatic, resourceful, intuitive, dedicated, resilient and proactive
· Strong verbal and written communication skills including motivational coaching, influencing and negotiation abilities
· Excellent time management and organizational skills
· Strong problem solving skills
· Ability to prioritize and manage changing priorities under pressure
· Proficient in Microsoft Office applications including Word, Excel, and PowerPoint and Outlook.
· Ability to proficiently read and interpret medical records, claims data, pharmacy and lab reports, and prescriptions required
· Ability to work closely with Health Home care coordinators, HCBS and other clinical providers.
· Ability to form effective working relationships with a wide range of individuals.
Licensure and/or Certification Required
· A valid NYS RN license.
· Clinical skills and subject matter knowledge.
· Must be able to learn and master UM/CM MetroPlus systems and procedures.
· Leadership and managerial capabilities.
· Must be able to work autonomously.
· Oral and written communication skills.
· Integrity and Trust
· Customer Focus
· Functional/Technical skills
· Written/Oral Communication