The Regional Case Management Director serves in the role of educator, advisor and consultant in order to facilitate the implementation and enhancement of case management best practices across the assigned Medicaid regions.
Leads the development and oversees the execution of policies and procedures, practice workflow, and data reporting for the Region. Directs the standardization of these functions. Assures quality member care and adheres to all relevant compliance activities. Develops trust, cooperation, and collaboration with administrative, medical staff and departments across the Region. Acts as primary clinical lead for assigned market(s), including support to the senior leadership team (including the state clinical account representative), and serves as the market clinical requirements expert. The states in this region includes California and Texas.
Collaborates with executive leadership throughout the organization to develop and implement program strategies that meet business, CMS, federal and state regulations as well as accrediting agency requirements
Oversees and ensures that day to day Case Management operations of the assigned Regions are completed in an efficient manner and in accordance with organizational policies and values.
Demonstrates problem-solving, critical thinking, and prioritization of work and resolves issues as they arise in an appropriate and timely manner.
Develops and executes on short- and long-term goals for the department consistent with established organization goals and objectives.
Creates and maintains collaborative partnerships with key providers (large medical groups, hospitals) works to establish collaborative relationships by fostering excellent customer response and appropriate problem resolution
Leads a team that promotes high standards of operational practice through advancement of policies, procedures, practice guidelines
Alignment of clinical and business processes and practices
Coordinates regional staffing efforts across the region; leads this effort on a day-to-day basis by accessing schedules and real-time information on unexpected staffing gaps such as call offs. Communicates to all case managers (and supervisors) asking for their assistance to fill these staffing gaps across the region.
Contributes at the most senior level by working across strategic and business units to set, engage and achieve objectives of the organization. Demonstrates the ability to critically evaluate and provide input to areas outside own area of expertise. Acts as a coach and positive role model for staff by establishing and maintaining a safe work environment that fosters positive morale
Market Clinical Lead (assigned market)
Serves as the assigned market clinical point of contact for state regulatory agencies to address contract compliance concerns, member/provider complaints and regulatory reporting timeliness
Lead and manage the development, review and delivery of market specific clinical reporting requirements both scheduled and adhoc
Support development teams with regulatory questions and requests.
Lead development of responses to regulatory authorities' requests for information.
Maintain responsibility for keeping abreast of changes and proposed changes to the assigned market regulatory requirements related to our clinical programs and processes.
Timely completion of all required reports to applicable regulatory agencies, such as applications, Periodic Performance reviews, corrective action plans, measures of success and reportable changes in institutional leadership or services as required.
Coordinates the development, implementation, follow-up and evaluation of corrective action plans in response to external accreditation bodies' citations and/or audit bodies when there are identified areas for improvement.
At least 7+ years' experience demonstrated in managing a team.
Previous Medicaid Managed Care experience (5+ years) having worked with state regulators and executed on strategic initiatives and programs
Strong leadership experience, strategic vision and a proven ability to execute on clinical initiatives are a "must have" in this position. 5-7 years management or clinical leadership
Competent in data analysis and uses this to drive medical management strategy
Knowledge of medical management regulations, standards, and policies
Ability to evaluate and interpret data for the purpose of developing and revising new programs and processes to meet business demands
Ability to provide leadership to staff and to build the trust and respect of internal and external key stakeholders. Able to motivate staff and promote team building
Ability to communicate in a highly effective manner with internal and external constituents in both written and oral format
Excellent written and verbal communication skills
Excellent problem-solving skills, including creativity, resourcefulness, timeliness and technical knowledge related to analyzing and resolving medical/administrative problems
Sensitivity to needs of culturally and linguistically diverse member, caregiver, provider and employee populations
Exceptional emotional coping skills, adequate to confront difficult emotional situations and emotional responses of others
Proficient in Microsoft Office Suite products including Word, Excel, PowerPoint and Outlook, plus a variety of other word-processing, spreadsheet, database, e-mail and presentation software
This job requires use and exercise of independent judgment
Bachelor's in Nursing required, or Master's in Social Work required.
Master's in Nursing or other related healthcare graduate degree preferred.
Active unrestricted State Licensure in applicable functional area. (e.g. RN, LPC, LCSW)
Bachelor's degree or equivalent experience
Percent of Travel Required
0 - 10%
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