Salary: $114,000.00 – $183,000.00
Client is seeking a Director, Care Management to join their team.
TX: Registered Nurse
We have to have someone that has the following experience:
- Case Management
- Utilization Review
- Managed care – preferably Medicaid
- Leadership and developing managers
- Process improvement/ gaining efficiencies
- Team building
- RN – Texas license
We’ve made a promise to improve the health of every child in our region. All of our employees come to work every day with that promise in mind, guiding them as they help our patients and their families get better and stay healthy. You can be an important part of making that happen.
Responsible for the planning, organizing, implementation, and management of all medical management functions. This position is also responsible for monitoring the Care Management Program and LTSS Program to assure compliance with the requirements of external regulatory and accreditation agencies.
DUTIES AND RESPONSIBILITIES
- Develops and maintains policies and procedures for the Care Management Program, including utilization review (precertification, concurrent, retrospective), discharge planning, catastrophic case management, long term services and supports, and case management for disease management programs.
- Maintains daily oversight of all Clinical Programs to ensure compliance with departmental policies and procedures as well as all contractual and regulatory requirements.
- Analyzes and trends in variances and makes appropriate recommendations for further review or action. Prepares and submits written monthly medical management data in accordance with Health Plan reporting requirements.
- Facilitates liaison relationships with payor representatives for whicour Health Plan has delegated utilization management agreements. Prepares reports as required by the payor.
- Determines department structure and staffing, Develops job descriptions for the Care Management staff and reviews these annually. Establishes and oversees staff development and evaluation programs. Provides staff with ongoing training, in-services, and continuing education opportunities to enhance performance and improve service by the Care Management Department to its internal and external customers
- Develops, implements, and manages the Health Plan’s Medical Necessity Denial and Appeal processes. Assures processes are in compliance with all regulatory requirements.
- In collaboration with the Health Plan Medical Director, develops, implements, and manages the Health Plan Quality Management program for the Care Management Department. Develops, implements, and directs an interrater reliability process to ensure standardization in the utilization review process for non-physician reviewers.
- Works directly with the Assistant Vice President of Network Management to identify needs for additional providers as well as to identify provider and staff education needs.
- Prepares and submits annual capital and operating budgets. Manages approved monies to ensure that a positive variance is maintained.
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