Neighborhood's employees come from a diverse background but all are committed to creating a more equitable health care system. Our array of experiences allows us to have a broad perspective and great creativity in facing whatever challenges arise. Unlike many other health insurance companies, we have nearly 30 nurses and social workers on staff. This structure speaks to our focus on active and compassionate care management for our members; we know that people who are alienated from the health care system require additional advocacy, outreach and support.

Neighborhood offers an exceptional compensation package to employees. We annually review base salaries/benefits and adjust as appropriate.

Medical Management Team Lead

Overview: 

The Team Lead of Medical Management provides oversight for specific Care Management or Medical Review programs/activities and works collaboratively with the Health Care Team to manage and coordinate care in order to ensure quality, and cost-effective patient-centered care.

Qualifications:        

·         RN, BS licensed in RI, Masters preferred

·         Supervisory skills

• 5 or more years experience in health care (HMO and case management preferred)                 
• Case Management Certification preferred                                                                     
• Broad clinical experience with special needs and with chronic medical conditions   
• Experience with medical care management required                                              
• Experience in behavioral health care management preferred                                                                        
• Clinical experience preferred                                                                                    
• Knowledge of medical, behavioral health and social services systems of care for individuals with special health care needs including disease management principles               
• Computer literacy with windows based programs                                                           

·         Strong organizational and documentation skills                                                               

• Excellent Customer Service orientation                                                                           

·         Strong interpersonal skills                                                                                                    

• Strong consumer advocacy skills                                                                                           
• Demonstrated ability to work as a part of a multi-disciplinary team                                         
• Strong verbal and written communication skills         
• Flexibility to work some evening hours
• Bilingual (English/Spanish) a plus

Duties and Responsibilities:      

·         Manages staff scheduling functions including daily assignments, coverage issues, time off requests, attendance monitoring, and payroll authorization

• Coordinates day-to-day operational activities
• Assists in settings performance standards and productivity measures
• Monitors program statistics, compliance and adherence to performance standards
• Assists Manager with development and design of new programs as assigned
• Provides direct oversight and serves as a clinical resource to the Medical Management Team in making case management care coordination and appropriateness of care recommendations/decisions
• Assists manager in identifying educational opportunities for staff

·         Supports Manager in completion of the performance review process and implementation of staff development plans

• Monitors clinical outcomes and assists manager in evaluating outcomes

·         Coordination of orientation for new staff in medical management

·         Ensures comprehensive training of new staff including supervising home visits as required

• Communicates with staff via one-on-one meetings as delegated by manager

·         Recommends opportunities for improvement in care coordination operational processes for assigned programs

• Assists manager in development and revision of specific policies and protocols
• Serves as primary contact at Neighborhood for Providers, families and other community resources as assigned
• Serves as liaison to community resources, as needed

·         Represents Medical Management on committees and in external marketing and education presentations as assigned as assigned by Manager

• Participates and assists with performance measures, quality improvement activities and regulatory requirements

·         Takes responsibility for own professional development and competency requirements.

• Other duties as assigned by the Manager

Specific to Team Lead for Care Management

·         Utilizes case management principles and sound clinical judgment in coordinating care for members with special health care needs

·         Performs intensive case management functions for identified individuals when needed in order to promote quality, cost-effective outcomes, including:

-          Performing a comprehensive assessment

-          Conducts home visits if required

-          Care planning activities including the development of interventions, short and long-term goals in collaboration with member, family, PCP, and other involved health care professionals and community agencies, as appropriate

-          Implementation of the defined plan of care, and facilitation of the referrals and coordination of services and community resources

-          Continuous monitoring and evaluation of the care outcomes and identification of service gaps

-          Regular review and revision of the plan of care in collaboration with the family and appropriate members of the health care team based on the outcomes and evaluative findings.

-          Provide comprehensive documentation of all Care Planning and resource management activities in Acuity

-          Coordinates medical and behavioral health services

-          Works collaboratively with all health care agencies

Specific to Team Lead for Clinical Management

• Reviews denial letters and packets, performing QC audit prior to mailing

·         Reviews requests for appeals, assigning them to the appropriate staff and/or physician consultants to review and ensures compliance with regulatory timelines and standards

• Performs pre-certification, concurrent and retrospective review of out-patient and in-patient services, including onsite and/or telephonic, using established criteria, Neighborhood plan benefit guidelines, and clinical judgment, to determine appropriateness of medical services, procedures, and care setting
• Refers and discusses complex case or cases that do not meet established criteria and guidelines with the physician advisor

·         Communicates with hospital staff, including but not limited to, physicians, case managers, and rehabilitation therapists, to ensure timely discharge planning and placement in most appropriate setting

·         Evaluates requests for outpatient services such as home care, therapies and DME and makes authorization decisions based on medical necessity and the ongoing needs of the individual patient

·         Reviews requests for Conditional Benefits and utilizes established Neighborhood clinical guidelines to determine medical necessity.  Presents to physician advisor for authorization decision as necessary

• Identifies and documents cost savings that may result from medical review process (i.e. bed downgrades, change to observation status, alternative setting, etc…)
• Communicates with ancillary departments as well as external providers as necessary to clarify benefits, medical review policies, and to meet individual needs of members and providers
• Meets department and regulatory standards for accuracy, proficiency and documentation in order to communicate decisions and plan of care in an appropriate and timely manner

Neighborhood is an EOE M/F/D/V and an E-Verify Employer.