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Job Summary:
To partner with MAPMG and Health Plan Operations in the achievement of service and clinical quality delivery objectives and goals specific to population care. To ensure the development and implementation of evidence-based population care management programs for targeted populations of members in accordance with established standards and guidelines.
Essential Responsibilities:
- Serve as the point of contact for health care services information and referral for members of special needs populations.
- Participate on the KPMAS consumer advisory board as a representative of special needs populations.
- Educates providers and staff on the requirements of P.L. 101-330, American with Disabilities Act of 1990, 42 U.S.C. §12101 et seq., acting as a resource to both providers and enrollees on the Disabilities Act.
- Monitors a log of each denial of treatment and the outcome of the utilization review for all referrals for special needs populations.
- Serve as the point of contact for behavior health services information and referral for members who need mental health and substance use services. Make recommendations for behavior health services and interventions.
- Facilitate monthly behavior health rounds with the states behavior health administrator.
- Participate in the regional workgroup that monitors members at risk of abusing prescription drugs.
- Audit Preparation: Conduct internal audits and chart reviews. Organize materials in preparation for audits and ensure that documentation meets quality standards. Communicate with key stakeholders throughout the audit process.
- Participate in the development of data collection and reporting tools.
- Training and collaborating on workflows.
- Perform other duties as assigned.
Basic Qualifications:
Experience
Basic Qualifications:
- Minimum two (2) years of experience working with special needs populations or the disabled required.
- Minimum two (2) years of experience working with Medicaid populations.
Education
- Masters degree.
License, Certification, Registration
- Licensed Clinical Social Worker (Virginia) within 3 months of hire
- Licensed Clinical Social Worker - Certified (Maryland)
- Independent Clinical Social Worker License (District of Columbia) within 3 months of hire
Additional Requirements:
- Excellent oral and written communication, organization, time management, problem solving, critical thinking, and clinical skills.
- Must be proficient with using Excel, PowerPoint, MSTeams, and Outlook.
Preferred Qualifications:
- Case Management experience preferred.
- Experience in a leadership role with or without direct reports preferred.
- Project management and/or program management experience preferred.
- Familiarity with Code of Maryland Regulations (COMAR) preferred.
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