About the job
Position: Population Health Management Clinical Liaison, RN
Client: Large Payer Client
Location: 100% Remote (Must reside in California)
Start Date: ASAP
GENERAL SUMMARY:
The Population Health Management Clinical Liaison, RN, PHN will report to the Director of Children’s Service, Population Health Management. The Population Health Management Clinical Liaison, RN, PHN interfaces with both DHCS and L.A. Care Health Plan, External Local Government Agencies and External Local Health Departments including California Department of Public Health. The out of plan agencies are the following but not limited to 1) California Children’s Services (CCS); 2) School District (Early Start, Early Intervention); 3) Regional Center (Developmentally Disabled); 4) HCBS (EPSDT/IHO); 5) MTU; 6) GHPP 7) HSD, 8) LA BHT workgroups, 9) LA CCS Workgroup, 10) HSD CCS Sub-Committee, 11) HSD Committee, 12) CHDP, 13) Local Education Agency, 14) Denti-Cal, 15) Child Welfare/Foster Care
Responsibilities:
- Supports the Children’s Leadership Team in setting goals, providing direction, and supporting implementation of clinical initiatives with strategic partners in alignment with APL 23-029 Memorandum of Understanding for Medi-Cal Managed Care Plans and Third-Party Agencies.
- Evaluate data and when appropriate perform observation of existing clinical practices which can include offices, hospitals, skilled nursing facilities and other extended care environments to aid in improving workflows and assist in the redesign of existing clinical programs. Work alongside partners in external environments to help implement improved processes.
- Assist in the evaluation and identification of opportunities around high-risk clinics and work side by side with external partners in the design and launch of clinical programs focused on high-risk hospital discharges, group visits, pain management and other initiatives aimed at ensuring access to preventative care and decreasing inpatient and emergency department utilization.
- Partner with medical groups to help create or redesign care programs focused on ensuring care for the ‘sickest of the sick’ members. Bring care to members who might otherwise be hospitalized or unable to access care. Ensure palliative care programs are available where appropriate and when needed.
- Perform and co-create Care Management (Care Coordination and Case Management) programs encompassing a full spectrum of initiatives around the children health program. Work with partners to provide guidance and rapid cycle process improvement of programs.
- Responsible for day-to-day process analysis, and data analysis of all lines of business and innovative value-based care models to support affordability.
- Responsible for internal reporting, monitoring of TAT, and monitoring CoHC Savings
- Act as our Specialty Referral Outreach
- Responsible in performing Care Connect Testing, supports the team with IT and submitting service tickets, and other technical issues.
- Partner with internal and external teams to transformation organizations into high efficiency/high quality health organizations.
- Leads with a collaborative approach and an understanding of existing resources and relationships between/among partner organizations while moving them towards constructive change.
- Works cross functionally with Blue Shield of California internal teams to provide support both ad hoc and recurrent on initiatives.
- Influences and collaborates with hospital and physician groups.
- Influences and participates in process change and implementation.
- Participates in the development, design and launch of innovative care models.
- Exercises judgment in developing methods, techniques, and evaluation criteria for obtaining results.
- Provide input into designing strategies for alignment with business unit goals objectives.
- Participation in all program meeting updates by webinar assigned by Management for all of the above programs.
- Developing materials for training, compliance, and reporting of the above programs. Additionally, maintaining the materials up to date as new information develops and/or retires.
- Communicates updated information regarding the above-mentioned programs to the departments needing notification updates within the organization.
- Be the designee between L.A. Care and BSC Promise for CCS and Linked Services updates and/or communication.
- Provides additional training on CCS and Linked services to new hires and/or staff that require re-education.
- Supports the Children’s Services (CCS) Department with incoming all levels of authorization types (Inpatient, Pre-Service, Retrospective) by providing: Verification in eligibility; in collaboration with the RN Clinical Manager, Appropriate screening, Referrals to linked services, Develop and submit SAR, Data entry in the UM data systems, PEDI Assistance
- Conduct internal audit reviews of the CCS Department for regulatory compliance.
- Maintain a current knowledge of all Regulatory updates with regards to CCS and the linked services
- Acts as a resource to providers or members for benefit/provider/health plan information.
- Creates extension and denial letters as needed.
- Support the Appeals and Grievance Process for both County CCS and Regional Centers, including Fair Hearings
- Responsible for assisting with high level CCS inquiries
- Other duties as requested by Manager of Medical Services, including supporting other members of the department as necessary.
Requirements:
- Requires bachelor’s degree in nursing, Active RN License, Public Health Nurse Licensure
- Requires at least 10 years of prior relevant experience
- 3+ years’ experience in consulting, project management, data analytics, operations, or a related field
- 3+ years of Medicaid experience (preferred Medi-Cal), Pediatric Expertise, preferred
- Understand at a member level how to coordinate care
- Strong emotional intelligence to communicate with a variety of different stakeholders
- Excellent verbal and written communication style to drive positive outcomes
- Strong data analytic skills
- Resourceful and collaborative: a team collaborator with strong listening skills and the ability to offer creative solutions to drive consensus. Experience working with State or County Children’s Programs and Regional Centers.
Preferred
- 3+ years data analytics experience
- 3+ years working with advanced Excel functions (formulas, pivot tables, vlookup, macros, etc..)