EPSDT Program Manager

Responsibilities: 

EPSDT Program Manager is responsible for all Market EPSDT reporting and program administration. Collaborates with the Enterprise EPSDT Corporate, Program Manager to lead and execute on Market EPSDT end-to-end process within the Wellness vertical and interacts with Population Health Management, Quality, Diversity-Equity-Inclusion, Member Engagement, Operations, Utilization Management, PerformRx and Provider Network Management., Corporate Enterprise Analytics and other disciplines across the Markets and Enterprise to:   

• Monitors performance to meet EPSDT contractual requirements; 
• Coordinates compilation and distribution of all reports due to operational, statutory and CMS; ensures the data is valid and reliable, proactively monitored, improved upon, and collected and delivered in an effective/timely manner; analyzes trends and bring trends to the appropriate functional area attention;
• Follows up to ensure any trends, recommendations and issues are resolved; recommends additional data gathering/compilation/review necessary to meet contract and performance requirements.
• Interacts with named functional areas to communicate needs of the EPSDT program as is applicable to each functional area.  
• Ensures all programs are being carried out, monitored and measured.  
• May be involved with Provider Education schedules and materials, EPSDT claim resolution and medical record audit coordination.  
• Participates in the development of Policies & Procedures, Standard Operating Processes, Training development and presentations to direct reports and other departments-internal and external
• Participates in regional and corporate workgroups and may assume lead role on some workgroups as delegated

Complies with AmeriHealth Caritas Family of Companies policies and HIPAA standards.

The EPSDT Program Manager (RN/LSW) assists members appropriate for care coordination and case management services in achieving their optimal level of health.  The EPSDT Program Manager (RN/LSW) must have relevant experience and education to work with Enrollees/Members with complex health, behavioral health, long-term services and supports and/or psychosocial needs and perform the following functions: 

• Provides access to a single point of contact for all questions or inquiries; 
• Conducts assessments with Enrollees and/ or their caregiver
• Develops guidance on  Individualized Care Plans that is periodically reviewed and updated; 
• Provides guidance on EPSDT disease self-management and coaching; 
• Conducts medication review, including reconciliation during transitions of care setting; 
• Provides periodic monitoring of health, functional and mental status along with pain and fall screening; 
• Ensures the provision of services in the least restrictive setting and transition support across and between specialties and care settings; 
• Connects members/enrollees to services that promote community living and help to delay or avoid nursing facility placement; 
• Coordinates with social service agencies (e.g., local departments of health, social services and community based organizations) and the referral of Enrollees to state, local and/or other community resources; and 
• Collaborates with nursing facilities to promote adoption of evidence-based interventions to reduce avoidable hospitalization, management of chronic conditions, medication optimization, fall and pressure ulcer prevention, and the coordination of services beyond the scope of the nursing facility benefit. 
• Ensure member/enrollee receipt of all EPSDT services;
• Ensure member/enrollee receipt of maternal and postpartum care;
• Promote family planning services;
• Promote preventive health strategies;
• Identify and coordinate assistance for identified member/enrollee needs specific to maternal/child health and EPSDT; 
• Interface with community partners and pregnancy related service coordinators; and
• Participate in EPSDT and maternal child quality and performance improvement efforts.
   

Education/Experience:

• Must be an Ohio licensed registered nurse, physician, or physician's assistant; or has a master's degree in health services, public health, or health care administration or another related field, and/or is a Certified Professional in Health Care Quality or CHCQM.
• Social services and/or clinical experience working with complex populations, including those with physical health, behavioral health, long-term services and supports and/or psychosocial needs.
• 3-5 years of Case Management experience preferred.
• Strong organizational skills, strong written and verbal communication, effective communicator for internal and external meetings, well-versed in Microsoft Office tools.