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It’s an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.
Job Summary:
The Clinical Delegation Manager is a registered nurse who supports delegated provider performance by monitoring relationships with delegated partners ensuring compliance, and achievement of organizational strategy as outlined in contracts. This position serves as a delegation subject matter expert and provides a broad range of coordination and operational support to the Office of Clinical Affairs (OCA), including the National Committee for Quality Assurance (NCQA) accreditation, quality improvement, and care management teams. The Clinical Delegation Manager is the key clinical delegation contact to the delegated provider’s leadership team regarding escalated issues as they arise. The position is responsible for both NCQA delegation oversight to the delegated providers and as a SME for all Population Health Management standards for internal and external partners. The Clinical Delegation Manager collaborates with various Boston Medical Center Health System population health management teams to ensure alignment of activities related to delegated quality contract requirements and adherence to NCQA accreditation requirements.
Our Investment in You:
· Full-time remote work
· Competitive salaries
· Excellent benefits
Key Functions/Responsibilities:
- Contribute to development and implementation of delegation best practices
- Build and maintain collaborative relationships with delegated provider and internal care management leadership to promote engagement with WellSense Population Health programs, optimize performance, and foster information exchange.
- Serve as the point person/subject matter expert (SME) for NCQA standards delegated to the providers, and issues submitted by the providers. Promptly resolve concerns or elevate to the appropriate level.
- Assist in the design of interventions to advance quality and efficiency initiatives and provide consultative support to delegated providers.
- Develop and maintain organizational policies and procedures related to delegation oversight.
- Lead regular delegation joint oversight meetings
- Quality performance
- Track common themes/structures/tactics across highest performing delegated providers and create best practice definition
- Engage delegated provider leaders and internal care management in the process of sharing best practices
- Monitor success of implemented quality measures
- Support NCQA delegation activities and ensure compliance with standards and regulations
- Conduct delegation oversight assessments
- Care Management performance
- Support the implementation and maintenance of care management programs (focused on particular disease states or more general) that will impact utilization metrics and health outcomes
- Conduct delegation oversight annual evaluation and ongoing audits; develop corrective action plans to remediate identified deficiencies
- Provider engagement
- Work with delegate provider leadership and staff to identify and implement best practices for engaging providers in population health programs
- Track engagement measures and share insights with WellSense leaders
- Track and Analyze Delegated Provider and Internal Care Management Performance
- Track performance metrics.
- Review and analyze data to assess quality performance.
- Advise WellSense leadership on performance improvement opportunities via the Care Management Steering Committee and/ or the Quality Improvement Committee.
- Work with Clinical Informatics, Network Management, Quality, Care Management, and Clinical Operations staff to assess performance and craft solutions to improve metrics.
- Other duties as assigned
Supervision Exercised:
Supervision Received:
- General direction received weekly from the Senior Manager Delegation and Quality Partnerships
Qualifications:
Education Required:
- Bachelor’s degree required.
Education Preferred:
- Bachelors of Science degree in Nursing (BSN) preferred
- Master’s degree (MSN, MBA, MPH, etc.) preferred
Experience Required:
- 7+ years of healthcare experience; some care management or outpatient ambulatory care experience preferred
- Advanced knowledge of NCQA PHM standards
Experience Preferred/Desirable:
- Experience within a managed care organization is strongly preferred
Conditions of Employment:
- Successful completion of pre-employment background check
Preferred Licensure, Certification
- Registered nurse with active license as applicable
Competencies, Skills, and Attributes:
- Project management training or comparable experience in managing complex interdisciplinary projects or programs.
- A strong working knowledge of Microsoft Office products.
- Detail oriented with excellent proof reading and editing skills.
- Effective collaborative and proven process improvement skills.
- Strong oral and written communication skills; ability to interact within all levels of the organization.
- Demonstrated commitment to excellent customer service.
- Knowledge and understanding of current trends in healthcare.
- Aptitude for aligning process, projects, and people to meet business goals in cross-functional team settings.
- Demonstrated past experience in delivering team success via data-driven metrics & reporting.
- Experience with matrix team management.
Working Conditions and Physical Effort:
- Regular and reliable attendance is an essential function of the position.
- Work is normally performed in a typical interior/office work environment.
- No or very limited physical effort required. No or very limited exposure to physical risk.
About WellSense
WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances. WellSense is committed to the diversity and inclusion of staff and their members.
Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status. WellSense participates in the E-Verify program to electronically verify the employment eligibility of newly hired employees.
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