Manager, Care Management and Complex Discharge Planning

Title: Manager, Care Management and Complex Discharge Planning

Organization Summary:

Community Care Cooperative (C3) is a 501(c)(3) non-profit, Accountable Care Organization (ACO) governed by Federally Quality Health Centers (FQHCs). Our mission is to leverage the collective strengths of FQHCs to improve the health and wellness of the people we serve. We are a fast-growing organization founded in 2016 with nine health centers and now serving hundreds of thousands of beneficiaries who receive primary care at health centers and independent practices across Massachusetts. We are an innovative organization developing new partnerships and programs to improve the health of members and communities, and to strengthen our health center partners.

Job Summary:

The Manager, Care Management and Complex Discharge Planning is responsible for daily management of the C3 Care Management Program which includes enhanced care coordination activities of MassHealth (Pediatric, Adult and Maternal Health) Member Populations. This includes day- to-day mentoring and oversight of an interdisciplinary Care Management team comprised of RN care managers, Behavioral Health care managers, and Community Health Workers. In addition, the Manager provides performance oversight to FQHC/APP (Affiliated Participating Provider) Care Management Teams to ensure care management services are delivered in a high-quality, cost-effective manner.

This position will oversee the Complex Discharge Planner role, which is responsible for supporting complex discharge planning across all FQHCs and APPs to reduce readmissions and improve continuity of care.

The manager is required to have a proficient understanding of MassHealth requirements to ensure care management workflows are implemented, in compliance with both federal and state regulations.

The manager works closely with the Director of Care Management and is responsible for performance and operational management of FQHCs/APPs participating in care management. Though this role is primarily “Hybrid,” it does require occasional office-based work in addition to in-person FQHC/APP- facing meetings.

Responsibilities:

• Assess and monitor team performance using program metrics, data, and management reports to assess caseloads, engagement rates, outcomes, and other process measures
• Using data and managerial tactics, the manager will monitor staff performance, including opportunities to improve and maintain performance standards
• In collaboration with the Director of Care Management, the manager will develop, monitor, and report performance improvement needs of staff and FQHC/APPs
• Perform chart audits, provide staff, and group supervision, and complete performance reviews, including mid-year and annual goal setting
• Address operational needs including vacancies, participate in the hiring of staff, manage the onboarding, orientation, and training process, as well as manage Personal Time Off (PTO) coverage
• Ensure staff are informed of policies and procedures and care management/program workflows
• Support the development of training content, including workflow updates that reflect most current MassHealth / CMS requirements, and participate in delivering training
• Build effective relationships with all external stakeholders including our primary customer, FQHCs and APPs

• Be first point of contact for urgent needs, such as staff managing complex patient issues/complex discharge plans member complaint and grievance issues pertaining to care management and escalating to Director/leadership as appropriate
• Prepare CM performance material (PowerPoint) tailored to each FQHC/APP or aggregated for meetings such as monthly clinical performance reviews
• Attend monthly FQHC/APP clinical performance meetings and ACO meetings, present care
• management program performance data, as well as make recommendations on areas of improvement
• Monitor performance trends and lead structured improvement initiatives for FQHCs and APPs not meeting targets
• Be well-versed in understanding technology tools that support the care management program, including the care management platform and Health Related Social Needs (HRSNs) screening tool
• Ensure special initiatives such as HRSNs and Care Needs Screening (CNS) processes are integrated into care management workflows
• Facilitate clinical rounds, coordinate/attend complex discharge planning case discussions and participate in care management clinical forums
• Special projects and other duties assigned

Required Skills:

• 3-5 years of supervisory experience in care management in a managed care environment; experience working with a Medicaid population is strongly preferred
• Pediatric, obstetrics, maternal/newborn experience highly desired
• Experience using Word Office products (Excel, Word, PowerPoint) 

Desired Other Skills:

• Familiarity with MassHealth ACO Program, Medicare Risk Contracts (REACH, MSSP, ACO-Flex)
• Familiarity with Federally Qualified Health Centers (FQHCs) or Community-Based Practices
• Demonstrated success in leading a multi-disciplinary team, including communicating and working with Health Centers, providers, primary care teams, nurses, Community Health Workers, and other organizations/programs such as SSOs (Social Service Organizations), and CSPs (Community Support Programs)
• Ability to navigate ambiguity and utilize clinical expertise to solve complex problems
• Ability to understand and interpret program and staff performance data analysis
• Experience working with patients with chronic medical, behavioral, and social health needs
• Must be flexible and adaptable to change
• Must demonstrate excellent interpersonal communication skills, written and presentation skills
• Familiarity with managing data, reporting, and using data driven reports to inform decision making and performance
• Ability to positively influence others with respect and compassion, and the ability to orient, motivate and build a cohesive team
• Experience motivating, inspiring, and building consensus across diverse staff
• Experience using appropriate technology, such as computers and Virtual Meeting Rooms for work-based communication
• Experience or familiarity working with CTC Epic/Epic, other EHRs, or Population Health Platforms (i.e., Arcadia)
• Experience with anti-racism activities, and/or lived experience with racism is highly preferred

Qualifications:

• Bachelor’s or higher degree in nursing with Massachusetts RN Licensure or Master’s degree in social work (LMHC, LCSW, LICSW) with MA state Licensure
• Case Management certification preferred
• A valid driver's license and provision of a working vehicle

** In compliance with Infection Control practices per Mass.gov recommendations, we require all employees to be vaccinated consistent with applicable law. **