Clinical Program Manager

About the role

The Clinical Program Manager supports cost-effective, high-quality health care for patients enrolled in long-term care facilities within a designated region. They manage a team of Providers and RN Case Managers, conduct clinical audits, and ensure compliance with Medicare, Medicaid, and other regulatory requirements.

Responsibilities

• Work closely with long-term care facilities and company leadership to meet key performance metrics
• Directly manage a team of Providers and RN Case Managers
• Ensure timely and effective delivery of patient services
• Collaborate with colleagues to develop innovative delivery models and care practices
• Serve as a subject matter expert on institutional special needs plans (I-SNP)
• Participate in clinical training initiatives
• Oversee the review and resolution of complaints and grievances
• Participate in company-wide quality improvement initiatives
• Review daily, weekly, and monthly management reports to monitor and manage care delivery
• Collaborate with vendors and community organizations for improved service delivery
• Manage stress appropriately and handle multiple priorities effectively
• Make decisions under pressure and demonstrate independent discretion/decision making
• Handle multiple priorities effectively and manage stress appropriately
• Ensure care is provided in compliance with all state laws and regulations
• Detect, prevent, and correct fraud, waste, and abuse

Requirements

• Ability to work designated schedule, reliable attendance
• Skilled business background
• Proficient leadership skills
• Knowledge of HEDIS and STAR ratings
• Knowledge of Medicare, Medicaid, I-SNP, Nursing Facility and Managed Care
• Vast experience in leadership and business
• Extensive knowledge and experience with Medicare, Medicaid, I-SNP, Nursing Facility and Managed Care
• Preferred HEDIS / STARs experience
• APRN or PA license required

Qualifications

• Education: Master’s degree in nursing
• Experience: 3 to 5 years’ experience in long-term care or with chronically ill patients
• Experience: 3-5 years of practice experience
• Experience: 1-3 years management experience in long-term care, home health or chronic condition management preferred
• Experience: Extensive knowledge and experience with Medicare, Medicaid, I-SNP, Nursing Facility and Managed Care
• Skills: Vast experience in leadership and business