Care Management Director

About The Company

PEHP Health & Benefits is a division of the Utah Retirement Systems that proudly serves Utah's public employees through high quality and competitively priced medical, dental, life, and long-term disability insurance plans on a self-funded basis. As a government entity, we embrace both a public mission and a commitment to creating customer value, excelling in the market, and improving healthcare. We offer a competitive salary with generous benefits, personal development in a positive team environment, and excellent work-life balance.

Job Description

POSITION SUMMARY

This key position supports PEHP's efforts to improve the health of members. The successful candidate leads PEHP's care management efforts and collaborates with members and providers and PEHP staff. Daily efforts include leading care management, disease management, utilization management, data analysis of current projects, reporting, and coordinating member care. The successful candidate is well organized, communicates complex clinical instructions in a way members and non-clinical coworkers can understand, strong clinical background, high integrity, and exemplifies the organization's vision of teamwork, innovation, and service.

ESSENTIAL DUTIES & RESPONSIBILITIES

Directs prior authorization, case management, and disease management activities within the department. Plans, develops, and implements utilization management, case management, and disease management interventions at PEHP. Evaluates the performance of preauthorization and departmental nursing related programs. Identifies opportunities for improvement and efficiency. Aligns programs with PEHP priorities and strengths. Meets all team deadlines and responsibilities, develops team members to maximize potential, helps team members meet goals, welcomes newcomers, and promotes a team atmosphere. Supervises training, coaches employees, delegates assignments, coordinates special training, and sets employees goals and priorities in a timely and efficient manner. Directs the operations of the Clinical Management Department and monitors work flow to assure timely completion. Evaluates worker performance, job retention, advancement, discipline, and discharge. Participates in recruitment and selection process for new hires. Applies strategic planning to assist in meeting the division objectives. Assists in establishing departmental priorities. Promotes PEHP and department policy. Aligns authorizations, denials, outreach, and education with PEHP policy and priorities. Upholds PEHP policy in response to disputed claims, appeals, or other reviews. Collaborates with internal and external customers. Reports effectiveness of utilization management, case management, and disease management interventions. Monitors the results of changes to utilization management, case management, and disease management interventions. Adjusts programs to meet PEHP objectives. Changes existing workflow based on results, market opportunities, internal efficiencies, and market trends. Identifies and reports outliers, high costs, or reinsurance cases. Provides guidance and decisions on authorizations, outsourcing, or case closures. Responds to internal customers regarding medical necessity and appropriateness of services and prior authorizations. Audits departmental activities and uses the results to improve performance. Coordinates on site visits of local health care facilities by PEHP nursing staff. Coordinates clinical outreach to new groups to facilitate a smooth transition to PEHP. Educates the nursing staff on non-protocol decision making. Promotes a collaborative atmosphere with internal and external customers. Maintains strict confidentiality in compliance with all applicable federal and state laws. Performs other duties assigned.

Required Experience

Education and Experience

Bachelor's degree in nursing and seven (7) years of progressively responsible experience in a broad spectrum of nursing, utilization review, and/or medical case management; or an equivalent combination of education and experience. Must be a Registered Nurse (RN).

Previous experience in a managed care organization is preferred.

Certification in Medical Case Management (CCM) is preferred.

Certified Professional Coding certification is preferred.

Knowledge, Skills, and Abilities

This list contains knowledge, skills, and abilities that are typically associated with the job. It is not all-inclusive and may vary from position to position:

Required technical skills include the working knowledge and ability of:

• Microsoft Office Suite.

• Internal proprietary system(s)/applications.

• Health Care Information Systems.

Required mathematical skills include working knowledge of:

• Calculating discounts, interest, and percentages.

• Calculating allowed amounts and member cost share.

Must possess significant knowledge of:

• Medical case management and claims review procedures and processes.

• Available community resources.

• Insurance benefits and design.

• Health Care Coding.

Must possess excellent communication skills:

• Interpersonal communication skills, both verbally and in writing.

• Negotiation techniques.

• Ability to draft technical reports, documents, and agreements.

Must have the ability to:

• Understand department reports, utilization patterns, and cost.

• Interpret clinical information and assess implications for treatment plans.

• Manage and coordinate varied operational functions and activities.

• Analyze a variety of health care issues and make recommendations.

• Problem solve and use sound judgment in decision making.

• Maintain effective working relationships with professionals, department heads, co-workers, and the public.

• Follow written and verbal instructions.

• Prioritize work.

• Perform within deadlines.

• Work well in a team environment as well as independently.

• Multi-task by handling a variety of duties in a timely and efficient manner.

• Follow through with assignments.

• Deal effectively with stress caused by workload and time deadlines.

The incumbent must always demonstrate judgment, high integrity, and personal values consistent with the values of URS.

Work Environment

Incumbent performs in a typical office setting with appropriate climate controls. Tasks require a variety of physical activities which do not generally involve muscular strain, but do require activities related to walking, standing, stooping, sitting, reaching, talking, hearing and seeing. Common eye, hand, finger dexterity required to perform essential functions.

Position requires occasional travel for office business. Individual must be physically capable of safely operating a vehicle, possess a valid driver's license and have an acceptable driving record based upon data provided by a current Department of Motor Vehicle Record (MVR).