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The Manager, Case Management (Clinical) is responsible for the direct oversight of internal and external case management processes including the development and implementation of policies, procedures and program development. In addition, the Manager, Case Management (Clinical) is responsible for supervising the Supervisors, Case Management (Clinical) to ensure that quality of coordinated care and cost effective services are available to all members in accordance with all applicable State and Federal regulatory requirements, Santa Clara Family Health Plan (SCFHP) policies and procedures, and business requirements for all lines of business.

ESSENTIAL DUTIES AND RESPONSIBILITIES To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below.

Collaborate, develop, implement and manage all case management processes for continuous compliance with all applicable State, Federal, National Committee for Quality Assurance (NCQA), SCFHP policies and procedures and general business requirements, for all lines of business. This includes but not limited to Centers for Medicare and Medicaid Services (CMS), Department of Health Care Services (DHCS), and Department of Managed Health Care (DMHC) regulations. Maintain a thorough knowledge of applicable laws and regulations in order to effectively monitor and ensure compliance with CMS, DHCS, DMHC and other applicable agency and program requirements. Develop and implement continuous analysis and quality monitoring of all policies and procedures to evaluate staff performance and ensure regulatory compliance, including the development and implementation of effective, measurable corrective action plans to meet targeted strategic outcomes. Ensure the integration of case management operations into other internal and external teams/departments including Quality, Long Term Services and Support (LTSS) and Behavioral Health (BH). Develop and track metrics related to program activities including collecting, analyzing and reporting by appropriate reports. Oversee all non-clinical care coordination staff including personal care coordinators. Create and maintain process workflows and procedures that are in compliance with regulatory requirements. Provide strong oversight and regular auditing and monitoring activities to ensure care management program guidelines are followed. Provide all required reports to regulatory agencies and internally to SCFHP management.

REQUIREMENTS – Required (R) Desired (D) The requirements listed below are representative of the knowledge, skill, and/or ability required or desired.

Active and unrestricted Registered Nurse (RN) or Licensed Clinical Social Worker (LCSW) license in the state of California. (R) Bachelor’s degree in a healthcare or related field; or equivalent experience, training, or coursework. (R) Master's Degree in healthcare or related field. (D) Certification in Case Management. (D) Minimum two years of progressively responsible experience in a supervisory capacity in case management or utilization management in a managed care or health care setting. (R) Demonstrated knowledge of Medicare and Medi-Cal benefits, Centers for Medicare and Medicaid Services (CMS), Department of Health Care Services (DHCS) and Department of Managed Health Care (DMHC) regulations. (R) Demonstrated knowledge of National Committee for Quality Assurance (NCQA) Standards. (R)

Santa Clara Family Health Plan (SCFHP) is a local, community-based health plan dedicated to improving the health and well-being of the residents of Santa Clara County. Working in partnership with providers and community organizations, we serve our neighbors through our Medi-Cal and SCFHP DualConnect (HMO D-SNP) health care plans.