Disease Management Manager (DC Medicaid)

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Job ID: 13704

Job Function: Customer Service & Claims

Location: Washington, DC, United States

Campus: DC-Washington-YARDS

Career Band: BDB

Status: Full-Time

Resp & Qualifications

PURPOSE: The Manager supports the Director of Case Management and the CareFirst Mission of providing affordable health insurance and accessible health care to all. The Manager role will provide oversight of the NCQA accredited health plan disease management program designed to coordinate care and identify appropriate providers and facilities throughout the continuum of services, while ensuring that available resources are being used in a timely and cost-effective manner in order to obtain optimum value for both the enrollee and the reimbursement source. The Manager will adhere to the principle of the Quadruple Aim - improving enrollee experience, better outcomes, improved clinical experience, lower costs while pursuing health equities for our enrollees.

The Manager set team direction, resolves problems and provides guidance to members of the team to ensure the team meets established performance metrics and performance guarantees. The manager builds an effective, efficient workforce to support all aspects of the Disease Management department across the continuum of care settings and clinical programs and services for enrollees. This includes the planning, implementation, and refinement of disease management programs and initiatives for medical management that support departmental and divisional goals. The Manager will oversee the work of non-clinical staff including Disease Management Coordinators and contingent workers. The role works closely with the Chief Medical Officer, Director of Case Management, Program Manager and Business Analyst and develop and operationalize sustainable processes to support functional improvements for the organization.

The Manager oversees a staff of:

Disease management coordinators

Contingent worker (intern)

Responsibilities include:

setting weekly performance goals and monitoring if benchmarks are achieved

participate in quality initiatives such as PIP and HEDIS

attendance at medical management operations and rounds meetings

administration of payroll and time tracking for case management supervisors

training of all new staff to medical management and disease management

maintain schedule to audit 10 cases per week for each disease management coordinator quality and training

oversee performance review process for direct reports

submit weekly medical management metrics to the medical management operations meeting

prepare monthly reports for HEDIS care gaps closed

document performance improvement plans as needed

help develop new disease management programs


Under the general direction of the Director of Case Management, the DM Managers accountabilities include, but are not limited to, the following (specific goals for Case Management Department are determined on an annual basis in accordance with directives from the executive board of CareFirst Community Health Plan Blue Cross Blue Shield):


Identification/Risk Stratification:) Engages enrollees into the disease management program (outreach and successful enrollment) using diagnostic cost grouper classification reports, which identify the relative risk score and illness burden.

Assessment: Screens enrollee to determine level of acuity within disease-specific tiers.

Planning: Proficient disease management knowledge and experience to coordinate Primary Care Physician (PCP), specialists and other healthcare providers/vendors appointments. Emphasis place upon close of HEDIS care gaps for diabetic and asthmatic population.

Facilitation of Communication and Care Coordination One key responsibility of the disease manager is to minimize the fragmentation of care services and adverse outcomes.

Monitoring: Documentation will reflect the necessary communication with the enrollee, family, physicians, and other health care providers to ensure the enrollees progression in meeting the established goals.

Outcomes Management: Evaluate the extent to which the established goals have been achieved.


Portal Data Base: Case management documentation is completed in the Care Connect system

Claims: Assists in claims inquiries and resolution

Legacy Systems (MHC, Care Connect and OSSE): Confirms enrollee eligibility and available benefits

Care Planner Web: Authorization management; generates coverage and adverse decision correspondence using appropriate language to meet state, federal and all regulatory requirements

Employer Group/Accreditation Audits: Participates in the preparation and on-site reviews (NCQA, OSR and DHCF)

Knowledgeable of federal/state mandates as they apply to various plan contracts

Documentation Audit: Responsible for completion of documentation review and peer to peer audit as assigned by management

MCG Chronic Care Guidelines: Familiarity with and usage of for the purpose of discharge planning (and length of stay review for FEP Line of Business only)

NCQA Compliance: Responsible for adherence to the NCQA Complex Case Management Standards and Health Plan Standards

CMSA: Adheres to the CMSA Standards of Practice for Case Management

HIPAA: Maintains confidentiality of patient information according to HIPAA and departmental policies.


Compile reporting for metrics and gaps of care

Responsible for payroll, attendance and time off scheduling to ensure adequate coverage


Disease Management Coordinators

SCOPE DATA: Incumbent is responsible for ensuring the quality of case management documentation meets NCQA standards for Health Plan accreditation for the target population.


To perform the job successfully, an individual should demonstrate the following competencies:

Analytical | Experience working with statistical methodologies, analytical and statistical theories. Knowledge of applied use of data in health program monitoring and evaluation.

Problem Solving - Identifies and resolves problems in a timely manner; Gathers and analyzes information skillfully; Develops alternative solutions; Works well in group problem solving situations.

Project Management | Communicates changes and progress; Completes projects on time and budget.

Technical Skills - Assesses own strengths and weaknesses; Pursues training and development opportunities; Strives to continuously build knowledge and skills; Shares expertise with others.

Customer Service | Manages difficult or emotional customer situations; Responds promptly to customer needs; Solicits customer feedback to improve service; Responds to requests for service and assistance; Meets commitments.

Interpersonal Skills | Solution oriented approach to conflict and challenges; Maintains confidentiality; Practices effective listening skills; Maintains professional demeanor; Remains open to others ideas and tries new things.

Oral Communication | Speaks clearly and persuasively in positive or negative situations; listens and gets clarification; Responds well to questions; Demonstrates group presentation skills; Actively participates in meetings.

Written Communication | Writes clearly and informatively; Edits work for spelling and grammar; Varies writing style to meet needs; Able to read and interpret written information.

Quality Management | Demonstrates accuracy and thoroughness. Applies quality assurance principles to data management activities.

Diversity | Shows respect and sensitivity for cultural differences; Promotes a harassment-free environment and respects diversity.

Ethics | Treats people with respect; Keeps commitments; Inspires the trust of others; Works with integrity and ethically; Upholds organizational values.

Organizational Support | Understands organizations goals and values and role in achieving those goals; Follows policies and procedures; Completes administrative tasks correctly and on time.

Strategic Thinking - Develops strategies to achieve organizational goals; Understands organizations strengths & weaknesses; Analyzes market and competition; Adapts strategy to changing conditions.

Judgment | Displays willingness to make decisions; Includes appropriate people in decision-making process; makes timely and data-driven decisions.

Motivation | Sets and achieves challenging goals; Demonstrates persistence and overcomes obstacles.

Planning/Organizing - Prioritizes and plans work activities; Uses time efficiently; Plans for additional resources; Ability to multi-task.

Professionalism Approaches others in a tactful manner; Reacts well under pressure; Treats others with respect and consideration regardless of their status or position; Accepts responsibility for own actions; Follows through on commitments.

Quality Demonstrates accuracy and thoroughness; Looks for ways to improve and promote quality; Applies feedback to improve performance; Monitors own work to ensure quality.

Safety and Security - Observes safety and security procedures; Reports potentially unsafe conditions.

Adaptability | Adapts to changes in the work environment; Manages competing demands; Changes approach or method to best fit the situation; Able pivot work with frequent change, delays, or unexpected events.

Attendance/Punctuality | Consistently at work and on time; Ensures work responsibilities are covered when absent; Arrives at meetings and appointments on time.

Dependability | Follows instructions, responds to management direction; Takes responsibility for own actions; Keeps commitments; Commits to long hours of work when necessary to reach goals; Completes tasks on time or notifies appropriate person with an alternate plan.

Initiative | Volunteers readily; Undertakes self-development activities; Seeks increased responsibilities; Looks for and takes advantage of opportunities; Asks for and offers help when needed.


LANGUAGE SKILLS | Ability to read, analyze, and interpret health and science periodicals, professional journals, technical procedures, or governmental regulations. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the public.

MATHEMATICAL SKILLS | Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent and to draw and interpret bar graphs. Knowledgeable of advanced statistical methodology.

REASONING ABILITY | Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.

COMPUTER SKILL | To perform this job successfully, an individual should have advance knowledge and proficiency in statistical data processing and visualization software such as Tableau, Spreadsheet software, and SAS, as well as Microsoft Office, Word Processing software, and SharePoint.

PHYSICAL DEMANDS | The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle, or feel and talk or hear. The employee is frequently required to reach with hands and arms. The employee is occasionally required to stand; walk; climb or balance; stoop, kneel or crouch.

The employee must regularly lift and/or move up to 10 pounds, frequently lift and/or move up to 25 pounds.

Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.

WORK ENVIRONMENT | The noise level in the work environment is usually minimal to moderate. The work environment is fast paced with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time. Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.

Required Education/Experience/Skills/Abilities:

Bachelors Degree

Masters Degree (public or population health, health administration, nursing) preferred

Three to five years of experience in health management in managed care, disease management organizations, healthcare providers.

Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.


The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights of up to 25 pounds are occasionally lifted.

Equal Employment Opportunity

CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

Hire Range Disclaimer

Actual salary will be based on relevant job experience and work history.

Where To

Please visit our website to apply:

Closing Date

Please apply before: 7/25/2020

Federal Disc/Physical Demand

Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.


The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.

Sponsorship in US

Must be eligible to work in the U.S. without Sponsorship
  • 1
  • Negotiable
  • None
  • None
  • Re-43896
  • Permanent
  • 2

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