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MEDICAL MANAGEMENT PROGRAM SPECIALIST
Job Field: Environmental Jobs
Location: Bay, CA
Salary: $Not stated
Location: Bay, CA
Salary: $Not stated
JOB SUMMARY:
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<tr><td valign="top" width="450"><b>Medical Management Program Specialist SCAN Health Plan« Back to Search FormDetailsLocation: CA - Bay Area Job Type: Health CareBase Pay: N/A Required Education: Not SpecifiedBonus: Required Experience: Not SpecifiedOther: Required Travel: Not SpecifiedEmployee Type: Full-Time Relocation Covered: Not SpecifiedIndustry Healthcare - Health Services, Social Services, Managed Care Job ID: 12-835 DescriptionJOB PURPOSE:To provide insight, guidance and leadership to network providers as a SCAN ambassador and member advocate leading to optimal member quality and the efficient delivery of quality services. To develop and maintain relationships with network providers that are of strategic importance to SCAN. To develop effective partnerships with the local provider community performing root cause analysis to drive the effectiveness of medical management programs to meet organizational strategic and operational objectives.ESSENTIAL JOB RESULTS:Facilitate care coordination, appropriate utilization and the timely delivery of quality care and services for SCAN members within the assigned region by acting as a consultant to and collaborating with provider groups, vendors, case managers, physicians and other impacted providers to ensure the appropriateness and quality of care. This includes the creation of new processes, as well as process improvement initiatives.Assess, evaluate and analyze utilization patterns and high cost complex admissions, streamline appropriate discharge parameters and create preventative steerage processes with physician groups in order to facilitate future admissions to the most appropriate facilities.Collaborate with SCAN health care analyst, to provide timely and relevant data/reports to key community stakeholders to assist them in making informed decisions in the area of cost trends, efficiency management and quality outcomes.As part of a team, provide insight in geriatric health management to providers, hospitals and community by developing materials, leading presentations, and providing information and referral sources related to various topics, including but not limited to end of life planning.Partner with provider groups to identify issues, barriers and opportunities for improvement that are of strategic importance to SCAN and provide recommendations and/or potential solutions to remedy such issues and barriers by working together to set and reach goals for continuous improvement in quality, service and the provision of cost-effective care.Facilitate internal SCAN meetings in order to ensure a coordinated, multi-disciplinary approach to medical group management.Facilitate quality care and service by referring any potential quality issue to the SCAN Medical Director and Quality Management Department.Perform and/or assist with utilization management and case management activities as necessary to diagnose and resolve system problems, or as deemed necessary by management.Maintain professional and technical knowledge by attending educational workshops; reviewing professional publications; establishing personal networks; participating in professional societies.Contribute to team effort by accomplishing related results as needed.RequirementsPREFERRED QUALIFICATIONS:Bachelor''s Degree in Nursing; Master''s degree preferred.License and Certification: Registered Nurse (Current and active California RN license in good standing).Case Management Certification (CCM) or Accredited Case Management (ACM) or Certified Professional of Utilization Management (CPUM) preferred.Five years experience in clinical nursing and five years experience in a medical group, IPA or HMO setting.Knowledge of Medicare, Medi-Cal, NCQA standards, HEDIS measures, Utilization Management, Case Management and Special Needs Plans preferred.Results-oriented, self-motivated.Proficient in Windows based applications, MS Word, Outlook, keying data to Excel.Excellent written and verbal communication skills.Excellent organizational skills.Ability to prio
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<tr><td valign="top" width="450"><b>Medical Management Program Specialist SCAN Health Plan« Back to Search FormDetailsLocation: CA - Bay Area Job Type: Health CareBase Pay: N/A Required Education: Not SpecifiedBonus: Required Experience: Not SpecifiedOther: Required Travel: Not SpecifiedEmployee Type: Full-Time Relocation Covered: Not SpecifiedIndustry Healthcare - Health Services, Social Services, Managed Care Job ID: 12-835 DescriptionJOB PURPOSE:To provide insight, guidance and leadership to network providers as a SCAN ambassador and member advocate leading to optimal member quality and the efficient delivery of quality services. To develop and maintain relationships with network providers that are of strategic importance to SCAN. To develop effective partnerships with the local provider community performing root cause analysis to drive the effectiveness of medical management programs to meet organizational strategic and operational objectives.ESSENTIAL JOB RESULTS:Facilitate care coordination, appropriate utilization and the timely delivery of quality care and services for SCAN members within the assigned region by acting as a consultant to and collaborating with provider groups, vendors, case managers, physicians and other impacted providers to ensure the appropriateness and quality of care. This includes the creation of new processes, as well as process improvement initiatives.Assess, evaluate and analyze utilization patterns and high cost complex admissions, streamline appropriate discharge parameters and create preventative steerage processes with physician groups in order to facilitate future admissions to the most appropriate facilities.Collaborate with SCAN health care analyst, to provide timely and relevant data/reports to key community stakeholders to assist them in making informed decisions in the area of cost trends, efficiency management and quality outcomes.As part of a team, provide insight in geriatric health management to providers, hospitals and community by developing materials, leading presentations, and providing information and referral sources related to various topics, including but not limited to end of life planning.Partner with provider groups to identify issues, barriers and opportunities for improvement that are of strategic importance to SCAN and provide recommendations and/or potential solutions to remedy such issues and barriers by working together to set and reach goals for continuous improvement in quality, service and the provision of cost-effective care.Facilitate internal SCAN meetings in order to ensure a coordinated, multi-disciplinary approach to medical group management.Facilitate quality care and service by referring any potential quality issue to the SCAN Medical Director and Quality Management Department.Perform and/or assist with utilization management and case management activities as necessary to diagnose and resolve system problems, or as deemed necessary by management.Maintain professional and technical knowledge by attending educational workshops; reviewing professional publications; establishing personal networks; participating in professional societies.Contribute to team effort by accomplishing related results as needed.RequirementsPREFERRED QUALIFICATIONS:Bachelor''s Degree in Nursing; Master''s degree preferred.License and Certification: Registered Nurse (Current and active California RN license in good standing).Case Management Certification (CCM) or Accredited Case Management (ACM) or Certified Professional of Utilization Management (CPUM) preferred.Five years experience in clinical nursing and five years experience in a medical group, IPA or HMO setting.Knowledge of Medicare, Medi-Cal, NCQA standards, HEDIS measures, Utilization Management, Case Management and Special Needs Plans preferred.Results-oriented, self-motivated.Proficient in Windows based applications, MS Word, Outlook, keying data to Excel.Excellent written and verbal communication skills.Excellent organizational skills.Ability to prio
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