Director Care Management - Health Plan Admin

Job Description

Summary:

This position is responsible for the direction, management, and leadership of the Care Management Department functions and processes of the hospital to include Social Work, RN Case Managers, and Utilization Review. The facility Director has oversight of Care Management functions and is responsible for ensuring timely and appropriate utilization review as set forth in COP §482.30 and discharge planning as set forth in COP §482.43 which is necessary to remain a participating provider with Medicare and Medicaid services.

Responsibilities:

• Responsible for the daily oversight of Care Management operations to include personnel management of department staff

• Responsible for developing programs that apply the CHRISTUS Health Plan mission, vision and values, healthcare science, incentives, and information to improve Care Management and assist consumers and their support system to become engaged in a collaborative process designed to manage medical/social/mental health conditions more effectively

• Assists with the development of the CHRUSTUS Health Care Management Framework that is used to design care management programs and to enhance consistency in services provided and reporting

• Assists with the outline and definition of the key components of a comprehensive care management program and provides examples of tools and strategies that can be used by CHRISTUS Health Plan in designing programs to effectively meet the needs of beneficiaries with complex and special needs

• Ensures State and Federal regulatory reporting, contractual compliance, oversight of related delegated vendor functions, in addition to Care Management operations, network supervision and staff management of Care Management reviews, Case Management, and coordination of linked and carved out service functions

• Ensures all functions are operating in accordance with the organization's mission, values and strategic goals are focused on continuous improvement; and are provided in a manner that is responsive and sensitive to the needs of the CHRISTUS Health patient population served

• Works with key partners within the CHRISTUS Health to represent CHRISTUS Care Management initiatives and/or programs

• Oversees delegated clinical functions at their facility/hospital insuring that care determinations are managed and monitored appropriately

• Works collaboratively with their facility's executive leadership, medical directors, managed care, operations, finance, and performance excellence to identify, develop, implement and monitor programs and processes

• Reports on program effectiveness to the Ministry/Regional Care Management Director, along with their local Executive leaders

• Responsible for facility Care Management clinical compliance from regulatory bodies such as CMS, HHSC, and DOD

• Responsible for their facility's Care Management department budgets

• Demonstrates ability to lead and motivate facility clinical and administrative teams to achieve specific objectives

• Demonstrates ability to understand and analyze complex business problems and apply cost effective solutions

• Maintains strong critical thinking skills, ability to make tough decisions and prioritization skills required

• Demonstrates successful experience working with multi-disciplinary teams in and across functional and organizational boundaries

• Demonstrates an ability to foster adoption of clinical technology and care delivery support systems across a range of environments and clinical contexts for all clinical applications

• Demonstrates knowledge of managed care including understanding of the physician, provider, payer and employer perspectives

Requirements:

• Bachelor's Degree required

• Demonstrates effective communication skills when writing and speaking.

• Demonstrates ability to set and meet established goals and objectives.

• Proficiency with Word Processing, costs effectiveness analysis

• Requires a minimum of 3-5 years full-time acute care nursing or social work experience

• At least 2 years in Case Management or Utilization Management experience required

• At least 3 years of leadership experience required

• RN or SW License in state of employment or compact

• Case Management Certification Preferred

Work Type:

Full Time

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Director Care Management - Health Plan Admin

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