Director, LTSS Clinical Care Management

About the role

Serves as the LTSS subject matter expert, leading RFP development and submissions while supporting the design, implementation, and growth of LTSS programs.

Responsibilities

• Directs the long-term care of members with physical/medical health needs and/or behavioral/mental health needs to develop and assess high quality, cost-effective healthcare outcomes.
• Develops strategies and objectives within long-term care management to improve member and/or provider experience.
• Provides leadership to the development, implementation, monitoring, and ongoing improvement of the long-term care management process.
• Sets goals and objectives for long-term care management team and oversees care management data and reporting metrics to achieve quality and cost-effective healthcare results.
• Works with senior leadership, as required.
• Leads long-term care management policies and procedures within the care management team to ensure compliance with corporate, state, and NCQA standards.
• Oversees and monitors work assignments and caseloads of long-term care management staff based on state requirements, care management staff experience, and member needs.
• Makes sure vendor oversight is done as required and applicable to the role.
• Attends conferences and stays updated on latest trends and best practices in Payer Care Management and related fields.
• Leads and presents process improvements for the long-term care management team to achieve cost-effective healthcare results.
• Coordinates large or special projects with other departmental functions.
• Directs and evaluates departmental operations, including the long-term care management model, staffing, use of information technologies, onboarding, and staff competencies to achieve performance and quality objectives.
• Monitors, reviews, and signs off on contract required reporting as required.
• Reviews and monitors long-term care member data to identify trends and improve operating performance and quality care in accordance with state and federal regulations, and participates with internal and external audits as required.
• Develops long-term care management strategies and influences decisions by providing recommendations that align to organizational objectives.
• Coaches and guides the long-term care management team to improve member and provider experience and facilitate delivery of high-quality care.
• Develops the overall strategy for onboarding, hiring, and training new long-term care management team members to ensure adequate training and high-quality care to improve member and/or provider experience and ensure compliance.
• Performs other duties as assigned.

Requirements

• Positions overseeing RN team members: Requires Graduate from an Accredited School of Nursing or a Bachelor's degree and 7+ years of related experience, including prior management experience.
• Or, Positions overseeing BH team members: Requires a Master's degree or Graduate from an Accredited School of Nursing and 7+ years of related experience, including prior management experience.
• Or equivalent experience acquired through accomplishments of applicable knowledge, duties, scope and skill reflective of the level of this position.
• 4+ years management experience preferred.
• Expert knowledge of industry regulations, policies, and standards preferred.
• Highly advanced clinical knowledge and ability to assess member needs in context of relevant diagnoses, treatment plans and goals, and identify potential gaps in care or risks for readmission or complications preferred.
• Strong knowledge of healthcare managed care principles preferred.
• Experience working with providers and healthcare teams to develop appropriate long-term service plans/care plans preferred.
• Strong knowledge of medication indications and side effects preferred.

Qualifications

• Current state’s Registered Nurse (RN) license required preferred or
• Licensed Clinical Behavioral Health Professional or RN based on state contract requirements e.g., LCSW, LMSW, LMFT, LMHC, and RN with BH experience required preferred.

Skills

• Expert knowledge of industry regulations, policies, and standards.
• Highly advanced clinical knowledge and ability to assess member needs in context of relevant diagnoses, treatment plans and goals, and identify potential gaps in care or risks for readmission or complications.
• Strong knowledge of healthcare managed care principles.
• Experience working with providers and healthcare teams to develop appropriate long-term service plans/care plans.
• Strong knowledge of medication indications and side effects.

Benefits

• Competitive pay
• Health insurance
• 401K and stock purchase plans
• Tuition reimbursement
• Paid time off plus holidays
• A flexible approach to work with remote, hybrid, field or office work schedules.