Nursing Director - RN (Health Plan)

Location: Local Hybrid: Local to the McMinnville, OR area, with flexibility to work both remotely and/or in-person at YCCO's office in McMinnville.

Most of the positions at YCCO are hybrid.

Yamhill Community Care (YCCO) is a Coordinated Care Organization (CCO), which focuses on health care and prevention. Our network of all kinds of health care providers (physical, dental and behavioral health) has agreed to work together. Members receive health care coverage under the Oregon Health Plan (Medicaid).

Learn more about Yamhill Community Care: click here

Department: Heath Plan Operations FLSA Status: Exempt

Reports To: Health Plan Operations Sr. Director Physical Strength: Light (L)

Summary

The Nursing Director

• RN is responsible for the successful oversight and leadership of the integrated Utilization Management (UM) and Care Management (CM) programs. Reporting through a dual role with the Chief Medical Officer (CMO) and Operations, this role promotes strong internal and external relationships and consistently meets regulatory requirements and contract deliverables. Responsible for the ongoing development and maintenance of the business systems to deliver Oregon Medicaid services and drive strategies for continuous quality improvement.

Essential Duties

• Directs the activities of responsible teams ensuring the Utilization Management and Care Management programs meet Oregon Administrative Rules (OARs), contractual obligations, and organizational policies.

• Effectively and efficiently manages a diverse workforce in a fast-paced, dynamic regulatory environment.

• Leads process improvement initiatives within responsible programs, working with a variety of departments and multi-disciplinary staff.

Job Duties

Integrated Program Leadership

• In a manner consistent with OARs and contractual compliance:

• Supports a culture of quality assurance and investment in the Yamhill Community Care (YCCO) mission, vision, and strategic plan.

• Oversees health transformation efforts related to health management programs.

• Represents YCCO across applicable State and system level activities and committees.

• Develops trust / credibility and collaborates with a broad range of internal and external partners.

• Directs the development of dashboards, and leverage data and other analytics to assure YCCO success in meeting benchmarks.

• Collaborates with the YCCO CMO to facilitate clinically driven UM and CM outcomes and operational logistics meeting OAR and contractual requirements.

• Develops and maintains policies and procedures.

• Participates in department budget development in ensuring appropriate staff, budget and other resources are available to meet organizational strategic and business plan goals, and corporate policy and procedures.

• Ensures effective communication and collaboration with the Oregon Health Authority (OHA), community partners, service providers, committees, and staff.

Quality Management

• Leads process improvement initiatives within designated programs, working with a variety of departments and multi-disciplinary staff.

• Develops and oversees CM and UM processes to ensure that activities, documentation, and reporting supports quality, timely, and compliant deliverables.

• Seeks consultation as needed, to support quality of care.

• Uses data to drive decisions and plans/implements performance improvement strategies related to UM activities.

• Creates reports displaying data and providing narrative analysis, to a variety of audiences.

• Identifies and facilitates resolution of system process issues impeding UM functions.

• Identifies and resolves delays and obstacles as appropriate.

• Leads and participates in process improvement initiatives, working with a variety of departments and multi-disciplinary staff.

Oversight of Health Management Program Deliverables

• Ensures the preparation and submission of regulatory and contract required deliverables are completed in a timely fashion.

• Ensures that documentation is entered in a clear, organized, and timely manner that is compliant with OAR / ORS (Oregon Revised Statutes) and contractual requirement.

• Develops and maintains policies, procedures, and protocols.

• Ensures ongoing compliance monitoring of department functions.

• Completes assignments, monthly statistics, and all other required reporting.

• Monitors designated programs for quality and risk concerns. Refer to appropriate departments as applicable.

• Participates in, and/or leads, assigned Committee and program activities.

Management & Leadership

• Trains, supervises, and evaluates performance of assigned staff.

• Provides department with ongoing understanding of the transformation, strategic plans, and operational direction of YCCO.

• Ensures adherence to department and organizational standards, policies and procedures.

• Ensures performance goals, expectations and standards are clearly understood by supervised staff.

• Performs human resource functions in collaboration with Human Resources.

• Ensures program expectations and standards are clearly understood by assigned staff.

• Provides staff with the training, tools, and resources necessary to carry out their work.

• Analyzes staffing needs and reorganizes work and assignments, as needed.

• Supervises assigned staff in a consistent manner.

• Evaluates assigned employees' performance both informally and formally and takes corrective action to address areas of opportunity.

• Performs human resource functions in collaboration with the Supervisor and Human Resources.

Essential Department & Organizational Functions

• Works to cultivate and develop inclusive and equitable services, and working relationships with diverse groups of employees, community partners, and community members.

• Participates in the preparation and submission of regulatory and contract required deliverables.

• Works closely with other YCCO departments, including Compliance to assist with audits; including the EQR, as needed.

• Proposes and implements process improvements.

• Meets deadlines for completion of assigned responsibilities and projects.

• Maintains agreed upon work schedule with punctual, regular, and predictable attendance.

• Demonstrates cooperation and teamwork using a professional and respectful demeanor.

• Provides cross-training on specific job responsibilities.

• Meets identified goals that contribute to departmental goals.

• Works collaboratively in a team and matrixed (cross-department) environment with a spirit of cooperation.

• Respectfully takes direction from Supervisor.

• Performs other duties as assigned.

Knowledge, Skills, & Abilities

• Demonstrate a working knowledge of regulatory and survey standards (Medicare, Medicaid, Joint Commission).

• Demonstrate a working knowledge of disease, including mental illness and addiction, and age specific impact.

• Demonstrate a working knowledge of rapid-cycle process improvement.

• Use Microsoft Word, Excel, PowerPoint, UM and CM software platforms, and other software tools for analysis and presentation of related data.

• Demonstrate positive and professional written, verbal, and nonverbal communication skills.

• Apply advanced critical thinking and conflict resolution skills using creative approaches.

• Ability to utilize negotiation skills, which effectively promote constructive solutions.

• Work collaboratively and professionally across YCCO teams as well as with external partners and the community.

• Excellent interpersonal communication, problem-solving, and conflict resolution skills.

• Knowledge in areas of: Medicare and Medicaid UM regulations, InterQual, HERC Guidelines, Medicare Inpatient Only List, RAC, QIO, MAC, and Denial Management.

• Excellent organizational skills including ability to handle multiple priorities and demands simultaneously in a dynamic work environment while maintaining high attention to detail and accuracy.

• Ability to work independently, use sound judgment, anticipate next steps and be proactive as part of a diverse team within a Matrix or shared resources across departments work model.

• Excellent computer skills, including Microsoft Windows, Word, Excel, and Outlook.

• Ability to communicate both professionally and effectively in all forms of communication.

• Ability to work in an environment with diverse individuals and groups.

• Ability to remain flexible, positive, and adaptable.

• Ability to work across the YCCO region and to work remotely, as needed.

Supervisory Responsibilities Directly supervises employees in the Utilization Management, Care Management, and Health Services teams. Carries out supervisory responsibilities in accordance with the organization's policies and applicable laws. Responsibilities include interviewing, hiring, and training employees; planning, assigning, and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems.

Qualifications

Ability to perform essential job duties with or without reasonable accommodation and without posing a direct threat to safety or health of employee or others. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties.

Education & Experience

Required:

• Bachelor's degree in Nursing or Master's degree in other Health Services, including Behavioral Health.

• Five (5+) years' experience supervising or leading teams.

• Three (3+) years' Utilization Management and Care Management experience.

OR:

• Any combination of education and experience would qualify candidate for the position.

Preferred:

• Eight (8+) years relevant experience.

• Five (5+) years' experience with Utilizations Management or Care Management experience.

• Experienced in physical and behavioral health integration.

• Experience with Coordinated Care Organization (CCO) / Medicaid Managed Care.

• Equivalent combination of education and experience will be considered.

Certificates, Licenses, and/or Registrations

Required:

• Valid, unrestricted Oregon RN license.

Preferred:

• ACM (Accredited Case Manager) through AMCA (American Case Management Association).

• CCM (Certified Case Manager) CCMC (Commission for Case Manager Certification).

• Board certification in Nursing Case Management (RN-BC) through ANCC (American Nurses Credentialing Center).

• CPHQ (Certified Professional in Health Care Quality) through NAHQ (National Association of Health Care Quality).

Physical Demands & Work Environment

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential duties of this position. The work environment characteristics described here are representative of those an employee encounters while performing the essential duties of this position. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential duties.

While performing the duties of this job, the employee is regularly required to talk or hear. The employee is frequently required to sit, stand, walk, use hands and fingers, handle or feel, and reach with hands and arms. The employee is occasionally required to climb or balance, stoop, kneel, crouch or crawl. The employee may occasionally need to lift and/or move up to 25 pounds.

This position operates in a professional office environment and requires frequent use of standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines. Specific vision abilities required by this job include close vision, color vision, distance vision, depth perception, and ability to adjust focus. The noise level in the work environment is usually moderate.

This position may include occasional required or optional travel outside of the workplace, in which the employee's personal vehicle, local transit, or other means of transportation may be used.