Director, Care Management (Medicaid, Hybrid)

Purpose of the job

Leads and manages all care management functions within the Medicaid Segment, to include but not limited to physical health, behavioral health, pediatric, and maternal care through an integrated care model to ensure compliance with all regulatory agencies and accrediting organizations. Evaluates and ensures that all organizational care management programs and resources are used appropriately and effectively, and oversees the collection, analysis, and reporting of financial and utilization data related to all utilization management and performance improvement activities. Accountable for achieving established performance targets through actively engaging multiple disciplines and professional staff and has responsibilities for managing people, relationships, and processes in order to achieve maximized results. Ensures the care management department achieves its goals and objectives by engaging internal and external stakeholders in care management processes across the Medicaid Segment. Promotes interdisciplinary collaboration, fosters teamwork across the organization, and champions performance improvement and goal achievement.

REQUIRED QUALIFICATIONS

Required Work Experience

• 5 years of management experience
• 5 years of managed care, health services, health outcomes, or disease management experience, specifically in developing and implementing clinical programs
• 3 years of experience with the Medicaid Care Management Operations
• 3 years of experience with accreditation standards

Required Education

• Bachelors degree in healthcare, healthcare administration, business administration or related field

• Required Licenses
  • Active, current, and unrestricted license to practice in the State of Arizona (a state in the United States) as a health professional, including RN, LCSW, LPC, LISAC LMFT, Psy.D. or Ph.D.
  • If the selected candidate does not possess an Arizona license, they are required before their date of hire to obtain a temporary valid unrestricted Arizona license to practice, while they work to obtain their Arizona license.

Required Certifications

• N/A

PREFERRED QUALIFICATIONS

Preferred Work Experience

• 7 years of management experience
• 7 years of clinical experience in a primary care field
• 7 years of managed care, health services, health outcomes, or disease management experience, specifically in developing and implementing clinical programs
• 3 years of experience with the state of Arizonas health care plan known as AHCCCS
• 3 years of experience with NCQA accreditation standards

Preferred Education

• Masters degree in healthcare, healthcare administration, business administration or related field N/A

Preferred Licenses

• N/A

Preferred Certifications

• N/A

ESSENTIAL job functions AND RESPONSIBILITIES

• Ensures care management compliance as defined by AHCCCS and NCQA are met and maintained.
• Leads and manages the care management staff in order to provide quality focused cost-effective interventions to all patients across the continuum of care.
• Establishes collaborative relationships with provider agencies, hospital care coordination teams, skilled nursing facilities, and the health plan clinical teams to meet the clinical and social service needs of the patient population.
• Oversees the day-to-day operations of the care management department and the use of systems to identify individuals and populations at risk and/or those in need of complex and chronic care case management.
• Works collaboratively with clinical leaders in developing and implementing programs and initiatives to address those issues.
• Monitors care management program effectiveness and efficiency and adjusts accordingly.
• Consults with the Staff VP of Clinical Operations and the CMO on the development of care management process and outcome analysis and reporting.
• Introduces and monitors care management tools and strategies and leverage technological solutions when possible.
• Maintains good vendor/client relationships where appropriate.
• Communicate health care and health management industry methodologies used for health management programs; develop and execute plans and articulate vision.
• Identify strategic directions/options for care management and wellness related systems and propose options, including budget forecasts, system roadmaps and functionality.
• Promote plan-wide understanding, communication, and coordination of population health management services.
• Manage use of corporate funds including budgeting, financial management, and reporting. Identify opportunities to achieve administrative efficiencies while maintaining service.
• Collaborate with Analytics to analyze utilization and identify opportunities to offer additional health management services to various customer segments, as well as trend analysis and development of services for program advancement.
• Analyze utilization, predictive modeling and clinical outcome data and provide ongoing analysis to appropriate executive members and committees of progress and priority issues.
• Assist with the development and integration of new products as they relate to areas of responsibility.

Health Management Operations

• Provide leadership over all of the care management operations of the Medicaid Segment including clinical training & auditing, medical policy, and ensure they meet the demographic and epidemiological needs of our members.
• Provide leadership, strategic direction and management support for care management and population management programs that improve health outcomes, as well as support applicable health-plan accreditation standards and HEDIS measures.
• Provide leadership, administrative and management support, strategic planning and overall direction of care management, utilizing the principles of continuous process improvement to impact efficiency, effectiveness and outcomes.
• Provide leadership and management in the support of the Care Management System including workflow, predictive analytics software, and online precertification to support business growth and evolving strategies. Oversee and coordinate from a Business Owner perspective, the business requirements, end-to-end testing and user acceptance testing for processes involving your areas of responsibility.
• Ensure appropriate productivity standards are monitored and in line with industry standards; analyze staffing models to support productivity and encourage efficiencies in process. Forecast staffing based trends, system changes and healthcare programs.
• Ensure all State, Federal, and Medicaid Segment accreditation and compliance requirements are satisfied for care management.
• Coordinate and assist in development of enhancements to existing systems or creations of new systems to improve efficiencies to processing.

Overall

• Demonstrate quality management standards in daily problem solving within respective areas of responsibility leading by example and managing by fact.
• Ensure new programs are integrated with all functional areas, including delegated entities, and responsive to competitive market demands.
• Function as an Subject Matter Expert for the care management programs and presents the programs to clients and other external agencies both in-person and written.
• Oversee day-to-day departmental administration by coaching and motivating managerial staff and departmental personnel to make maximum use of experience and skills.
• Monitor quality performance measures, develop and maintain effective workflows, and seek to maximize system efficiencies.
• Manage use of corporate funds including budgeting, financial management, and reporting. Identify opportunities to achieve administrative efficiencies while maintaining service.
• Provide leadership for accreditation activities for areas of responsibility.
• Participate in strategic planning activities and contribute to departmental and cross-functional teams to achieve BCBSAZs Medicaid Segments goals.
• The position requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as needed to meet business requirements.
• Maintain effective working relationships to ensure teamwork in achieving corporate goals.
• Perform all other duties as assigned.