The clinical manager ensures members in the Medicaid programs obtain care and services based on their individual medical, psychosocial and behavioral health needs; while concurrently improving quality, decreasing disparities and identifying cost savings opportunities across the line of business. Responsible for implementing contract and clinical requirements across all KPMAS Medicaid programs and ensures that KPMAS is in compliance with state, federal and member expectations. The clinical manager will implement the organization’s commitment to serving the community through participation in Medicaid programs. The activities described below pertain to KP Medicaid programs in Virginia and Maryland as well as participation in Priority Partners in Maryland.
Essential Responsibilities:
- Clinical Implementation: Identifies newly proposed program clinical changes as per guidance from state regulatory agencies. Analyzes new and existing Maryland and Virginia Medicaid contract and clinical requirements for downstream organizational implications. Develops and builds clinical requirements for cross-functional review, including applicable internal and external partners. Manages and facilitates process development and planning discussions with cross-functional stakeholders. Develops clinical implementation strategies and plans. Maintains relationship with cross-functional partners on an ongoing basis until the scope of work relating to clinical changes is complete. Monitors existing clinical changes in accordance with state regulatory guidelines. Manages relationship with external stakeholders regarding applicable clinical changes. Develop operational workflows and related materials for clinical changes.
- Regulatory Analysis: Assist with contract and regulatory interpretation and disseminate regulatory updates to appropriate KPMAS functional areas. Coordinate and draft KP responses to proposed changes to state regulation or Medicaid program changes (i.e., notices of proposed rulemaking or public comment), in collaboration with applicable cross-functional stakeholders.
- Communications: Develop periodic communications either organization-wide or to targeted audiences to ensure organizational partners understand current clinical requirements and policies. Disseminate proposed clinical workflows for collaborative approval from cross-functional stakeholders. Maintain KPMAS website for VA and MD Medicaid members. Manage KP Medicaid mailbox, the KP Medicaid SharePoint site, and portal access provided by external quality review organizations including The Delmarva Foundation and HSAG. Maintain functional area and department Medicaid contact list. Manage inquiries to and from the Medicaid Office as posited by functional areas or external stakeholders.
- Data Analysis & Other Duties: Run necessary analytics and reports in collaboration with Medicaid Office and IT stakeholders to aid in the deployment of newly developed programs. Other duties as assigned by the Senior Director of Medicaid Operations or Executive Director of Medicaid.
Basic Qualifications:
Experience
- Minimum two (2) years of experience in any combination of the following: health care delivery, case management or Medicaid.
- Minimum one (1) year of project management experience.
Education
- Bachelor’s degree in Nursing OR four (4) years of directly related experience required.
- High School Diploma or General Education Development (GED) required.
License, Certification, Registration
- N/A
Additional Requirements:
- Extensive knowledge of Medicaid health care delivery systems
- Extensive knowledge of current trends in care management and industry standards related to care delivery to Medicaid population
- Project management experience in health care or managed care setting.
- Knowledge of KP MAS or other health care organizations.
- Strong background working with Medicaid and/or Special Needs Populations with unique health care needs
- Excellent negotiation skills, verbal/written communication skills
- Strong analytical and strategic planning skills. Excellent public presentation skills.
- Strong persuasive and interpersonal skills.
- Demonstrated ability to work in a highly matrixed environment. Strong collaborative and team skills.
- Ability to interpret and communicate laws and regulations related to health care and Medicaid
- Experience in working with regulatory agencies and managing a large organization’s response to actions.
- Experience with budgeting; state and federal compliance; state and federal policies and laws
- Experience working within a large multi-disciplinary health care setting
- Broad knowledgeable of Medicaid programs and health care delivery systems to support low-income patients.
- Broad knowledgeable of current trends in care management and industry standards related to care delivery to Medicaid population
Preferred Qualifications:
- Extensive knowledge of Medicaid health care delivery systems.
- Extensive knowledge of current trends in care management and industry standards related to care delivery to Medicaid population.
- Project management experience in health care or managed care setting.
- Masters Degree in Nursing preferred.
COMPANY: KAISER
TITLE: Program Manager Medicaid Implementation
LOCATION: Rockville, Maryland
REQNUMBER:
External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with Federal, state and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran, or disability status.