Care Manager II – Delegation Oversight

Care Manager II – Delegation Oversight

Location: Cincinnati, OH

Primary Job Function: Medical Management

ID: 37926

Job Brief

Remote position. Valid Ohio RN or LSW license.

Your career starts now. We’re looking for the next generation of health care leaders.

At AmeriHealth Caritas, we’re passionate about helping people get care, stay well and build healthy communities. As one of the nations leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we’d like to hear from you.

Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.

Discover more about us at www.amerihealthcaritas.com .

Responsibilities:

This Care Manager / Coordinator Delegation Relationship Partner is an exciting and rewarding position. It will act as our Population Health departments Medicaid interface with our delegated provider groups. It will require auditing and reporting responsibilities for our provider and subcontractor delegation. This crucial position will ensure adherence with NCQA, state and business requirements. Specific responsibilities and task include but not limited to the following:

Supports Delegation Relationship for Ohio Medicaid Care coordination.

Conducts external pre-delegation and annual audits for new and existing delegated entities for Care Coordination. Will be required to interface with other areas of the organization (or SMEs) to complete audits on claims or other delegated functions, as needed.

Provides expert knowledge and guidance internally and externally around delegation oversight regulatory requirements and accreditation standards associated with auditing activities.

In coordination with Delegation Contract Coordinator conducts Ohio contract analysis across all lines of business to ensure plan delegation relationship and partnership oversight compliance elements are met.

Documents, evaluates and validates regulatory compliance with all requirements of all regulatory agencies.

Ensures subcontractor performance standards are met in accordance with statement of work agreement and regulatory requirements.

Collects and summarizes performance data, identifies opportunities for improvement and presents to Quality Improvement committees.

Maintains all documentation to support evidence of compliance with all delegation requirements.

Communicate credentialing operations and reporting requirements to delegated entities.

Assist in managing policies and procedures relating to credentialing and delegation oversight.

Assist with Credentialing / Quality Committee activities.

Report audit outcomes and delegation monitoring results to management .

Education/Experience :

Current and unrestricted Registered Nurse licensure in OH OR licensed Social Worker (LSW or LISW) in Ohio.

A Bachelors Degree (or higher) with a concentration in Business, Clinical / Healthcare (related field) or equivalent work experience.

Auditing or relevant oversight / supervisory experience required.

Critical thinking and problem-solving skills along with exceptional verbal, written and presentation aptitude.

Comprehensive ability to create, monitor, and analyze provider data.

Proficiency utilizing Tableau, SharePoint, MS Office (Word, Excel, Outlook, Teams) in a Windows-based environment, internet applications, and electronic medical record and documentation programs.

Must be able to work independently and foster essential relationships.

Diversity, Equity, and Inclusion

At Amerihealth Caritas, everyone can feel valued, supported, and comfortable to be themselves. Our commitment to equity means that all associates have a fair opportunity to achieve their full potential. We put these principles into action every day by acting with integrity and respect. We stand together to speak out against injustice and to break down barriers to support a more inclusive and equitable workplace. Celebrating and embracing the diverse thoughts and perspectives that make up our workforce means our company is more vibrant, innovative, and better able to support the people and communities we serve.

We keep our associates happy so they can focus on keeping our members healthy.

Our Comprehensive Benefits Package

Flexible work solutions including remote options, hybrid work schedules, Competitive pay, Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more.

EOE Minorities/Females/Protected Veterans/Disabled