Director, Case Management

Responsibilities

• Oversees medical and Care Continuum operations.
• Provides direct supervision to the managers and supervisors.
• Develops and monitors medical management staff care continuum training program.
• Participates on all clinical services committees.
• Develops and enhances system of management reporting and metrics to be utilized for productivity, adherence, and outcome measurements to provide relevant information on overall effectiveness in care continuum areas.
• Ensures department optimizes care continuum work flow efficiencies to meet company objectives.
• Ensures that all medical care continuum programs are delivered consistent with applicable internal policies and procedures as well as applicable CMS, BMS, NCQA or other regulatory agency requirements.
• Ensures appropriate care continuum programs are in compliance to quality outcomes e.g. STAR measures, HEDIS, CCIP, QIP and PIPs.
• Responsible for medical management/behavioral health annual risk assessment related to care continuum programs.
• Collaborates with the CMO, VP of Clinical Services, Director of UM and AVP of Population Health on initiatives and interventions to ensure cross-functional and inter-departmental alignment with organizational goals.
• Ledes medical management and behavioral health care continuum program integration with provider health systems.
• Implements and monitors medical management and third party care continuum program software.
• Provides input into clinical services medical/evidence based care continuum program criteria.
• Leads clinical services care continuum program compliance and NCQA initiatives.
• Interacts with government agencies, health systems, and employer groups to facilitate medical care program integration.

Qualifications

• Required: Registered Nurse with a minimum of 5 years clinical experience. At least two years of experience should be in a management capacity.
• Minimum of a Bachelor's of Science degree in Nursing or willingness to obtain within 2 year of hire.
• Holds active and unencumbered Ohio or West Virginia multi-state registered nurse license.
• Minimum of five years in a managed care organization.