Job Description

Program Overview

Help us elevate our patient care to a whole new level! Join our Aetna team as an industry leader in serving dual eligible populations by utilizing best-in-class operating and clinical models. You can have life-changing impact on our Medicare and Medicaid Program (MMP) members, who are enrolled in Medicare and Medicaid and present with a wide range of complex health and social challenges. With compassionate attention and excellent communication, we collaborate with members, providers, and community organizations to address the full continuum of our members’ health care and social determinant needs. Join us in this exciting opportunity as we grow and expand MMP to change lives in new markets across the country.

Position Summary

The Sr Manager – Clinical Health Services will oversee the implementation of healthcare management services for assigned functional area of Western and Southern OH including Toledo, Columbus and Cincinnati.

Fundamental Components

• Will lead a team of managers and individual contributors (approximately 80 in total) implementing change, driving efficiencies and promoting a culture that fosters accountability and joining forces

• Implements clinical policies & procedures in accordance with applicable regulatory and accreditation standards (e.g., NCQA, URAC, state and federal standards and mandates as applicable)

• Serve as a content model expert and mentor to the team regarding practice standards, quality of interventions, problem resolution and critical thinking

• Ensure implementation and monitoring of best practice approaches and innovations to better address the member's needs across the continuum of care

• May act as a liaison with other key business areas, internally and externally

• May develop/assist in development and/review new training content

• May collaborate/deliver inter and intra-departmental training sessions

• Protects the confidentiality of member information and adheres to company policies regarding confidentiality 

• Manages resources responsible for identification of members, development and implementation of care plans, enhancement of medical appropriateness and quality of care and monitoring, evaluating, and documenting of care

• Evaluate and interpret data, identify areas of improvement, and focus on interventions to improve outcomes

• Develop, initiate, evaluate, monitor, and communicate performance expectations

• Ensures the team's understanding and use of information system capability and functionality

• Participate in the recruitment and hiring process for staff using clearly defined requirements in terms of education, experience, technical and performance skills

• Assesses developmental needs and collaborates with others to identify and

implement action plans that support the development of high performing

teams

• Lead by example, and shape an environment and work style that promotes the concept

of teamwork, cross product integration, and continuum of care thinking that

results in strong performance

• Consistently demonstrates the ability to serve as a model change agent and lead change efforts

• Create a positive work environment by acknowledging team contributions, soliciting input,

and offering personal assistance, when needed Accountable for maintaining compliance with policies and procedures and implements them at the employee level

• Communicate effectively with Providers, Members, Staff and other Leaders (e.g., may provide support to the sales staff & network staff via onsite customer visits and/or presentations)

Requirements

* Seven years of experience working with Medicare and/or Medicaid

* Five years of people management experience

* Managed Care experience (external candidates)

* Registered Nurse with an active and unrestricted license in the state of OH

* Confidence working at home/independent thinker, using tools to collaborate and connect with teams virtually

* Project management experience and experience leading projects independently

* Advanced execution and delivery (planning, delivering, and supporting) skills

* Mastery knowledge of phases of care transitions and resources available for patients

Preferred

* Managed Care experience (internal candidates)

Education

Bachelor's degree preferred