The Program Manager Clinical Care Management will serve as the subject matter expert in driving Care Management and Coordination Program processes and outcomes to continuously improve timely access and high quality of care for Avēsis members. This role will be responsible for the development, oversight, and management of program processes performed by our shared services team, applicable to care coordination and case management services for members with special health care needs. This role will have oversight and manage the special health care needs requirements to include developing the assessment and reporting for the special health care needs population. This role will evaluate and identify disparities/social determinants of health, special health care needs and conditions, and/or other factors impacting member ability to access and coordinate needed care or impeding personal motivation to engage care. Specific to our Dental Home model, this role will oversee, manage, and lead the progression of referrals for specialty care and escalate timely to ensure members are connected to care for treatment needs incorporating social determinants of health. This role will be an active participant in the growth and evolution of the Quality Program through a multi-year strategy with phased annual goals.

This role is responsible for the oversight and clinical direction for the enrollment, identification, assessment, and facilitation of case management services, with integrated care coordination as needed, for members with special health care needs, through oversight and management of shared services program processes:

• Develop core workflow processes as needed, with a distinct emphasis on vulnerable members where case management efforts are integrated due to social determinants and/or special health care needs.
• Responsible for development, maintenance and revision of applicable policy, SOP, workflow, case collateral, and relevant training for shared services team.
• Ensure all contractual, regulatory, and accreditation standards are being met for clients and client audit activities related to social determinants of health and safety, care coordination, and care management.
• Specific to Dental Home, develop process and provide direct oversight to ensure timely authorization of referrals and/or referral changes, resulting in members being connected to necessary care, with escalation as appropriate.
• Support and lead potential quality issues (PQI) and develop aggregate reporting and refer to appropriate departments for resolution.
• Drive the development and growth of an evolving care management program, facilitating case management services and care coordination efforts and linkage, with eye on evolution toward patient navigation activities for contribution to ‘whole person’ service plan (e.g., safety; food/housing security; medical/behavioral integration).
• Development of descriptive and measurable program goals and outcomes (e.g., SMART).

• Registered Nurse (RN) required; Bachelors (BSN) or Masters degree preferred (MSN)
• Minimum of 5+ years managed care, Medicaid community-based organization, or direct delivery system experience in a member facing, quality, or operation related role.
• Dental and/or Vision specialty clinical practice knowledge a plus.
• Population and Health Equity experience highly desired.
• Strong proficiency and knowledge, with direct application experience with person centered / person planning / case management, care coordination / linkage, and integration with relevant medical, behavioral, and community service providers.
• Experience developing quality studies, reporting, quantitative and qualitative analysis.
• Strong written and verbal communication skills with focus on detail and concise, objective, relevant documentation.
• Demonstrated ability to create and deliver educational and training materials and presentations specific to role.
• Demonstrated skills in EMR/care management platforms, Microsoft Office Word, Excel, Visio, Power Point; willingness to learn/train to develop further proficiencies as related to job duties.
• A willingness to attain future CCM certification within 6 months, as applicable. (CCM a plus).
• The ability to accelerate impact and effectively collaborate across multiple teams toward attaining common goal and objectives.