Managed Care Programs Manager

The Managed Care Programs Manager Director is critical in fulfilling and advancing SCES’s mission of delivering exceptional care and community-based support to our clients and communities so that our clients can live independently and with dignity in the setting of their choice for as long as possible. They serve as a key liaison between health insurance plans and healthcare providers to ensure that members receive high-touch coordination of care through a person-centered approach tailored to meet the needs of the beneficiaries living in the communities served.

The Managed Care Programs Manager ensures that all contractual, regulatory, quality, and utilization requirements are met in accordance with federal and state requirements for all managed care contracts and identifies opportunities for growth and optimization. They find solutions to complex problems and are committed to eliminating silos within the department and providing leadership and guidance to our diverse managed care and transitions of care teams to promote advocacy and health equity for all members served.

Job Responsibilities and Performance Standards:

  • Responsible for the operational performance and continued success and viability of SCES’s Managed Care programs and functions. Works with key internal and external stakeholders to further develop, promote, and enhance these programs and the organization.
  • Responsible for overall staffing and supervision, budget monitoring, program operations, compliance, and quality assurance and improvement for managed care programs and functions.
  • Provide strong leadership, guidance, and mentorship to managed care staff by fostering a collaborative, encouraging, and inclusive work environment that promotes teamwork, professional growth, and a culture of accountability.
  • Ensure appropriate hiring, training, supervision, and performance management of managed care staff to increase staff retention and satisfaction.
  • Monitor staff productivity, documentation standards, and compliance in accordance with regulatory and contractual requirements. Ensures adequate staffing and manages caseloads for case managers, ensures home visits and telephonic encounters are conducted in a timely manner, on-call schedules are covered, and documentation is complete in the appropriate managed care portal and SCES system.
  • Promote accountability and follow-through within the department. Manages performance issues by following the appropriate processes and policies.
  • Collaborate with the Training and Workforce Development Manager on departmental training plans for new and existing staff and establish competencies and requirements for each role within the department.
  • Ensure that all policies and procedures are in place and adequately accessible for staff to reference for all managed care programs. Collaborates with the HCBS Director in developing new policies, procedures, and training for new programs and trains all staff.
  • Collaborate with the HCBS Director in developing and monitoring departmental key performance indicators and dashboards and work with managed care staff to ensure compliance and course correction when needed. Ensures all key indicators align with managed care contract requirements and quality measures.
  • Ensure that all quality, compliance, and utilization standards are met and participate in quality improvement activities internally and with other key stakeholders such as managed care payers.
  • Ensure that staff telephonic or face-to-face encounters with clients capture the necessary history and program needs assessments using a tool with pre-defined questions for identifying, evaluating, coordinating, and managing member’s program needs.
  • Ensure that the non-clinical needs of managed care members with chronic illnesses, co-morbidities, and/or disabilities are met to ensure cost-effective and efficient utilization of services.
  • Ensure staff establishes short- and long-term goals for managed care members in collaboration with the members, caregivers, family, natural supports, physicians, and managed care plan.
  • Identify members with potential clinical healthcare needs (including, but not limited to, potential for high-risk complications) and coordinate those member’s cases with the clinical healthcare management and interdisciplinary team to provide care coordination support.
  • Foster relationships with state agencies, referral sources, payers, and community-based organizations for further access and services for SCES clients.
  • Plan and facilitate staff meetings and other meetings as needed, ensuring that DEI and Health Equity principles are woven into these meetings and discussions.
  • Act as a liaison between SCES, EOEA, MassHealth/LTSS, and Managed Care programs.
  • Comply with HIPAA and other state and Agency confidentiality requirements.
  • Perform other duties as assigned.

Professional Standards and Conduct:

  • Leadership: Ability to lead, inspire, empower, and influence a large staff by demonstrating confidence and leadership presence. Delegates tasks, responsibilities, and authorities to others, sets reasonable expectations and follows through on their progress.
  • Collaborative and Responsive: Regularly communicates, follows up, and uses a team-driven approach. Responds thoughtfully and promptly to agency needs, requests, and inquiries; identifies and builds partnerships with key stakeholders. Has excellent organizational and time management skills to meet various deadlines, ensuring closed-loop communication, multi-tasking, and maintaining flexibility to adapt and adjust workload assignments based on various needs.
  • Communication: Skilled in verbal and written communication, demonstrating the ability to communicate information in various ways to meet diverse styles and cultural backgrounds.
  • Analytical: Critical thinking skills, using logic and reasoning to identify the strengths and opportunities of alternative solutions, conclusions, or approaches to problems.
  • Attendance and Punctuality: Dependable, punctual, showing flexibility when needed. Attends meetings as needed and is fully present and participates during those meetings.
  • Commitment: Passion and commitment to establishing and developing evidence-based programming for individuals to live in the setting of their choice with dignity and for as long as possible. Embodies SCES’s core values and shows great integrity, accountability, and professionalism in all interactions. Aids in furthering SCES’s mission and commitment to an inclusive environment.

Qualifications:

  • Bachelor’s degree in Public Health, Healthcare Administration, Nursing, Social Work, Gerontology, or a related field required. A Master’s Degree in these fields is preferred.
  • A minimum of 3 years of supervisory or management experience, ideally in an organized labor setting, is strongly preferred. Consideration for candidates with a combination of education and supervisory/management experience working in case management, capitated, managed care, or accountable care settings will occur.
  • Ideal experience should include oversight of home and community-based programs and long-term services and supports, ideally working in an ASAP (Aging Access Service Point) setting with OneCare, Senior Care Options, Accountable Care, and Medicare Advantage plans.
  • Must have knowledge of federal and healthcare regulations and experience collaborating between healthcare providers and insurance plans, using evidence-based strategies and resources to improve population health and utilization.
  • The ability to set and communicate clear quality improvement goals and expectations and promote quality excellence to meet all required regulatory requirements.
  • Demonstrated experience leading operations and project management tasks, including coordination, communication, prioritization, troubleshooting, adherence to budget, and completion of goals.
  • Must be knowledgeable and comfortable using Adobe and MS Word, Excel, PowerPoint, SharePoint, and other Microsoft 365 platforms required.
  • Must meet both CORI/SORI and public health screening requirements.

Physical Environment:

  • Physical surroundings are comfortable with minimal exposure to injury or hazards.

Social/Psychological Conditions:

  • Occasional stress due to periodic or cyclical workload pressures and deadlines. Some interruptions involved.

Physical Effort:

  • Frequently sits, stands, walks, bends, reaches, and stoops throughout the day.
  • Frequently lifts, pulls, pushes, and carries up to 20 lbs.
  • Periodic eye strain and light ear strain.