RN - Manager of Value Based Care
RN - Manager of Value Based Care
Posted on :
23-07-2025
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1 Vacancy
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Monthly Salary
Not Disclosed
Salary Not Disclosed
Vacancy
1 Vacancy
Posted on :
23-07-2025
Job Description
Job Purpose
We are seeking an experienced and motivated Registered Nurse (RN) to lead and manage our Inpatient Case Management and Complex Care Management programs. This leadership role is responsible for ensuring high-quality cost-effective care coordination for medically complex patients with a focus on Medicare Advantage populations. The ideal candidate will possess strong clinical judgment experience managing inpatient workflows and deep knowledge of Medicare Advantage regulations and risk-based care models. In addition the Manager will be responsible for contributing to the growth and success of HealthTexas while upholding our Mission Vision and Values.
Culture and Values Expectations
At HealthTexas we believe that our workplace culture is the cornerstone of our success. We are committed to fostering an inclusive collaborative and innovative environment where every Associate feels valued empowered and motivated to reach their full potential. Our culture is the driving force behind our mission to deliver quality and compassionate care with outstanding service every patient every time. As a Manager of Population Health Management at HealthTexas we expect you to embody and promote our Values and defined behavioral expectations.
- Integrity: Do the right thing the right way every time.
- Be honest and uphold commitments and responsibilities earn the trust and respect of the team and those we serve and maintain privacy and confidentiality.
- Compassion: Treat everyone with respect and dignity.
- Foster an environment of inclusivity and well-being practice patience and empathy and assume positive intent.
- Synergy: Collaborate to improve outcomes.
- Invite and explore new opportunities promote effective communication and teamwork take pride in yourself your work and HealthTexas.
- Stewardship: Use resources responsibly and efficiently.
- Implement effective strategies to attain goals achieve maximum productivity and results and seek continuous knowledge and improvement.
Essential Job Duties & Responsibilities
- Support growth and development of programs consistent with enterprise wide philosophy and in response to the dynamic nature of the health care environment through benchmarking for best practices networking and other activities as needed.
- Ensure the delivery of cost effective community-based and culturally sensitive case management interventions and continuous quality improvement monitoring.
- Develop and implement effective administration of Utilization Management policies and procedures aligned with federal state and health plan contract and regulatory guidelines.
- Direct Utilization Management and Complex Case Management projects and processes and evaluate effectiveness with proven ability to adjust programs to achieve desired outcomes.
- Understand the roles and relationships among medical management quality initiatives (HEDIS CAHPS Stars) and wellness programs within the medical group
- Prepare for and participate in regulatory audits
- Implement and continuously improve upon standard operational procedures that are consistent with federal state and health plan requirements
- Evaluate and monitor regulatory quality measures case management utilization management and Physicians expectations
- Coordinate with other operational departments to identify workflow best practices and develop and implement improvement initiatives
- Establish and maintain strong working relationships with Providers to ensure organizational performance goals and quality measures are met
- Ensure that the case management program provides for appropriate and cost effective medical services behavioral health services and medically related social services and that they are identified planned and obtained where needed.
- Oversight of facilitating access of medically necessary services when patients are admitted to a facility (listed above) and ensure that they are provided at the appropriate level of care in a timely manner acting as a liaison between patients and all providers to enhance communication and coordination of care.
- Review of the Utilization Management process such as EZ Cap authorization accuracy of data entry use of MCG and Medicare criteria for medical necessity review authorization letter generating appropriately and each CM is performing proactive discharge planning.
- Monitoring of the facility assignments and census for daily/monthly productivity measures and collaborating with VP of Value Based Care or other senior leadership when concerns or potential changes are needed.
- Ensure that team is providing consistent reporting in weekly Case Rounds and to Medical Directors presenting clinical information on current inpatient census discharge plans identifying potential cases for case management and service review and coordinating care with other Medical Management team members.
- Review and ensure the team is developing a Discharge Plan and identification of barriers to discharge that would require collaboration with Social Work Attending Physician patient/family or caregiver hospital/facility Case Manager and/or Medical Director.
- Ensure that authorizations required for discharge are completed such as Home Health DME and transfer to LTAC/ARU/SNF.
- When needed referrals to medical director for review of medical necessity when CM nurse is unable to approve services at the current level of care. Will comply with any UM requirements for referral to outside Physician reviewers appeals/denials or Notice of Medicare Non-Coverage (NOMNC) are to be provided.
- Maintains current knowledge of health plan benefits and provider network. Educate patient on health plan provider network appropriate levels of care to utilize (ARU LTAC SNF HH or Hospice) and other benefit plan programs available during inpatient events and post discharge.
- Comply with all guidelines established by the Centers for Medicare and Medicaid (CMS) if applicable.
- Assists with formulating and recommending organizational policies and objectives or changes in existing policies and objectives.
- Responsible for building and maintaining a unified high performing interdisciplinary team. Cultivates collaborative environment with preferred providers within network such as Home Health SNF DME Hospice and any other vendors affecting patient outcomes and delivery of services.
- Responsible for targets such as monitoring LOS Bed Days readmissions and potential financial impacts to the MA delegation.
- Ensure that weekend on call schedule is completed and communicated with HTMG teams for communication of who is on call.
- Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency.
- Other duties as assigned
Experience
- Minimum 5 years of clinical nursing experience with 3 years in case management or care coordination
- At least 3 years of leadership/managerial experience in a healthcare setting preferably in an inpatient or management care environment
- Direct experience with Medicare Advantage populations and CMS care management requirement
- Strong knowledge of utilization management discharge planning care transitions and complex case management
Knowledge Skills & Abilities
- Strong oral and written communication to prepare and present program process.
- Strong leadership and team-building skills.
- Strong interpersonal and organizational skills.
- Strong knowledge of Medicare Advantage and Commercial health plans.
- Demonstrated ability to organize prioritize and multitask efficiently.
- Proficient in MS Office and computer systems (e.g. patient management software).
- Exceptional organizational and leadership skills.
- Good analytical and problem solving skills.
Work Hours Travel Requirements
- Monday Friday 8:00 a.m. 5:00 p.m. in office and as needed to complete projects.
- Travel to medical offices or administrative office may be necessary for the purpose of providing education or interdepartmental meeting attendance.
Working Conditions & Physical Requirements
- Requires working under stressful conditions where constructive criticism from others is encouraged. Requires working extended or irregular hours (including evenings and occasional weekends) as the medical group determines necessary or desirable to meet its business needs and/or the needs of its patients. Requires prolonged sitting some bending stooping and stretching and occasional lifting up to 50 pounds. Requires eye-hand coordination and manual dexterity sufficient to operate a keyboard photocopier telephone calculator and other office equipment. Requires normal range of hearing and eyesight to record prepare and communicate appropriate reports. Normal office environment.
Please note this job description is not designed to cover or contain a comprehensive list of activities duties or responsibilities that are required of the employee for this job. Job responsibilities location work hours etc. may change at any time with or without notice.
Required Experience:
Manager
Employment Type
Full Time
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