Director of Managed Care

Job Summary: Lead and manage all functions within case and disease management programs to ensure consistent, efficient delivery of services throughout the healthcare continuum and demonstration of positive outcomes. Oversee medical management functions to ensure consistent, efficient delivery and achievement of utilization targets.

Essential Functions:
• Leadership role in transitioning to the “next generation” of Care Management.
• Continuous review of business workflows to improve productivity and ensure member and p rovider satisfaction.
• Facilitate and promote problem identification, analysis and resolution.
• Expand ability to meet State contract requirements with proactive processes to ensure success.
• Ensure monitoring of regulatory requirements and oversight of all submissions.
• Determine benchmarks, goals and outcomes for all programs as well as high cost, volume and risk conditions.
• Determine benchmarks, goals and outcomes for staff and implement an accountability system.
• Monitor CQI activities in accordance with regulatory requirements and URAC standards.
• Develop and coach employees.
• Build succession plan for Director and Manager positions.
• Foster relationships with hospitals, physicians and community agencies.
• Identify “wellness continuum” opportunities and develop successful blending of case, disease and medical management functions.
• Identify and report risk management issues for the department and CareSource as a whole.
• Perform any other job related instructions as requested, with reasonable accommodation.Education:
• Current, unrestricted RN licensure in t he state of practice required
• Bachelors degree in nursing or relation field required
• Masters degree preferred
Experience:
• Five years’ experience in case management, medical management and quality improvement in a MCO
• Two years’ management experience
• Experience in Disease Management preferred
• Experience in Medicaid and/or other Government programs (Aged, Blind and Disabled, Medicare etc.) preferred.
• Experience in Medicaid MCO preferred
Certification:
• Managed Care, Utilization management Case Management and/or Quality Improvement certification preferred.
Technical Skills:
• Basic level skills utilizing Microsoft Word, Excel and PowerPoint
• Intermediate Microsoft Office skills preferred
• Internet research skills preferred
Knowledge & Skills
• Leadership experience and skills
• Change agent
• Decision making/problem solving skills
• Clinical data analysis and trending skills
• Critical and ‘systems’ thinker
• Knowledge of trends in healthcare, managed care, Medicaid, case management, medical management and quality improvement.
• Excellent communication skills (verbal and written)
• Management skills (Human capital and project management)
• Multiple years prior supervisory skills
• Ability to work independently and within a team environment
• Attention to detail
• Understanding of predictive modeling process/tools
• Training/teaching skills
• Strategic management skills
• Negotiation skills/experience
• Politically astute
• Program grammar usage, phone etiquette and technical writing skills
• Time management skills
• Customer service oriented