About Texas Children's HospitalFounded in 1996, Texas Children’s Health Plan is the nation's first health maintenance organization (HMO) created just for children. We provide STAR/Medicaid and Children's Health Insurance Program (CHIP) to pregnant women, teens, children and adults in Houston and surrounding areas. Currently, the Health Plan has more than 375,000 members who receive care from our network of more than 1,100 primary care physicians, 3,200 specialists, and 70 hospitals. Texas Children's Health Plan is also the largest combined STAR/CHIP Managed Care Organization in the Harris County service area. To join our community of 14,000+ dedicated team members, visit texaschildrenspeople.org for career opportunities. You can also learn more about our amazing culture at infinitepassion.org Texas Children’s is proud to be an equal opportunity employer. All applicants and employees are considered and evaluated for positions at Texas Children's without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, gender identity, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.
We are searching for a Manager Case/Disease Management—someone to supervise and provide social case management services to Texas Children's Health Plan members and to continually develop the identification outreach and delivery of social supports as needed to respond to the strategic goals of Texas Children's Health Plan.
Think you’ve got what it takes?
• Provides supervision of case management services.
• Attends MCO/State Fair Hearings for service and waiver appeals.
• Provides coverage as needed to meet program goals.
• Participates in interdepartmental groups to represent case management needs in different aspects of TCHP including utilization management, provider relations, operations, finance, quality improvement and member services.
• Maintains adequate levels of qualified and competent staff in the department by collaborating with the Leadership Team in the recruitment and hiring of departmental employees.
• Facilitates orientation of staff to the department and provides appropriate feedback and evaluation of progress.
• Maintains accountability for scheduling and staffing needs and budgetary guidelines.
• Assists in the establishment goals for performance standards.
• Serves as a liaison with community agencies and other groups and organizations which impact Medicaid health services.
• Serves as a representative for case management process internally with TCH IDS and externally with TCH customers and community partners
• Maintains current knowledge and contacts with alternate sites for appropriate health care delivery within the community and the state needed for pediatric population.
• Monitors and evaluates new community resources on an ongoing basis to continue to meet the identified needs of TCHP members.
• Participates in state audits of the MDCP program and ensure staff compliance with contract case management requirements.
Being fully vaccinated against COVID-19 is required for all employees at Texas Children’s, unless approved for a medical or religious exemption
• Bachelors Degree in Nursing OR Health Education OR Social Work OR in a comparable Public Health Field
• LCSW (Texas Behavioral Health Ex Council), or LMSW (Texas Behavioral Health Ex Council), or RN (Texas Board of Nursing or Nursing Licensure Compact)
• 5yrs experience in health delivery or a managed care organization (health insurance experience acceptable)
*case management certification preferred, but not required*
• Applying highly technical principles, concepts and techniques central to the nursing profession in the case management process and general managed care and specifically with complex pediatrics and obstetrics.
• The ability to operate a personal computer, word processing programs, fax machine, spreadsheet program, electronic medical record, photocopier and multi-line phone.
• Must have a comprehensive understanding of case management principles and general knowledge of NCQA and HEDIS measures.
• Must have excellent written and verbal communication skills, impeccable negotiating skills, and the ability to interact with a wide variety of individuals and handle several complex situations simultaneously.
• Must have evidence of leadership, creativity, integrity and initiative, and sound problem-solving skills.
• Must provide attention to detail and follow up
• Must possess demonstrated project management skill