Director, Ambulatory Care Management and Operations - Value Based Service Organization - Full Time 8 Hour Days (Exempt) (Non-Union)

About the role

The Director, Ambulatory Care Management and Operations, is responsible for the leadership, operational oversight, and overall performance of the Value Based Services Organization's care management team and clinical programs across a matrix organization.

Responsibilities

• Serves as a senior leader resource in collaborating with executives to establish program objectives and develop enterprise-level ambulatory care management strategies and solutions.
• Contributes to the development of business requirements for each ambulatory care management program, ensuring alignment with organizational goals and compliance with regulatory standards.
• Defines, documents, and refines key processes necessary to support sustainable, high-performing programs.
• Oversees the development of clinical content, including but not limited to assessments, evidence-based clinical guidelines, and patient/family education materials.
• Directs the creation and delivery of orientation, training, and ongoing competency programs for departmental staff.
• Provides leadership and oversight of program operations and staff performance, including recruiting, hiring, mentoring, and supporting professional development for all program positions.
• Ensures that medical services across inpatient, outpatient, and post-acute settings are delivered at the most effective and appropriate level of care based on the patient’s medical needs.
• Builds and sustains high-performing teams that can meet both current and future program goals and objectives.
• Oversees workload distribution, productivity, and effectiveness of staff, ensuring operational and clinical goals are met.
• Leads collaboration with interdisciplinary teams (IDT), facilitating forums, and supporting care managers in providing coordinated services that promote cost-effective, high-quality outcomes.
• Serves as a clinical and operational consultant to ambulatory care managers, providing second-level expertise and problem-solving support for complex patient care decisions.
• Oversees and ensures comprehensive documentation for patients in this program, including but not limited to network and out-of-network hospitalizations, SNF stays, observation status, discharges, CCM census, new assessments, and interventions.
• Ensures departmental compliance with all applicable regulatory and accreditation standards, including health plans, NCQA, Joint Commission, federal and state requirements, and internal Health System policies.
• Leads and participates in care management activities to ensure that newly implemented processes, programs, and workflows are effective and sustainable.
• Analyzes and evaluates care delivery processes to identify and address gaps, reduce unnecessary duplication, and maintain cost-effective, high-quality care.
• Applies advanced clinical knowledge and experience in assessment, planning, implementation, and evaluation to the oversight of care management activities.
• Maintains expertise in applying current clinical guideline-based criteria, including but not limited to CMS, InterQual, MCG, and health plan standards.
• Employee Management: Ensure that management staff understand basic wage and hour laws, federal, state and local laws and regulations, Medicare, and legislation affecting employment in outpatient and nursing services.
• Plan, organize and supervise all clinical and support staff(s) to ensure high quality, cost effective patient care.
• Direct and approve staffing plans to promote the maximum use of all personnel and the reduction or addition of staff based upon patient load ratios and organizational outpatient guidelines.
• Ensure that continuing education programs are offered to keep staff up to date on nursing practices, universal precautions, worker/patient safety etc.
• Responsible for all employee activity such as hiring, promotions, performance evaluations, salary increases, and disciplinary actions with appropriate approvals from the Executive Administrator and HR Administrator; includes all bonuses, performance reviews, employee performance management, compensation reviews, etc.
• Ensure that the performance evaluation program meets organizational guidelines.
• Lead regular staff meetings with Clinic Administrators or other program facilitators as necessary.

Requirements

• Bachelor’s Degree Nursing BSN
• 5-10 years Clinical experience with 3+ years of experience in ambulatory case management in a leadership role.
• Demonstrated leadership ability, team management and interpersonal skills. Ability to effectively communicate with personnel from diverse backgrounds.
• Strong written and verbal communication and interpersonal skills.
• Excellent analytical, critical and abstract reasoning skills, plus excellent organization skills.
• Intermediate to advanced computer skills in Microsoft Office programs including Word, Excel, and PowerPoint.
• Knowledge of CM standards, UM standards, clinical standards of care, NCQA requirements, CMS guidelines, Milliman guidelines, InterQual guidelines, and Medicaid/Medicare contracts and benefit systems is preferred.

Preferred Qualifications

• Master’s degree Nursing MSN
• 3 years Experience in an HMO/IPA/Managed care setting is preferred.
• Certified Case Manager - CCM (CMSA)
• Certified Utilization Review Professional

Required Licenses/Certifications

• Registered Nurse - RN (CA Board of Registered Nursing)
• Valid California Registered Nurse license.
• Basic Life Support (BLS) Healthcare Provider from American Heart Association
• Fire Life Safety Training (LA City)