Apply online at http://www.alohacare.org/Careers/Default.aspx The Opportunity: The Director, Behavioral Health CCS, is responsible for directing the case management team and the care management of members to develop and assess high quality, cost-effective healthcare outcomes. The Director develops strategies and objectives within care management to improve member and/or provider experience. The Director is accountable for creating a culture that is integrated, collaborative, inter-disciplinary, data-driven, transparent, innovative, and sound in managed care fundamentals.
Primary Duties and Responsibilities: - Provides oversight of AlohaCare's CCS program to ensure compliance with requirements/standards set by DHS, CMS, MQD and NCQA.
- Direct and evaluates departmental operations, including the case management model, staffing, use of information technologies, and staff competencies to achieve performance and quality objectives.
- Oversee case management team on performance, improvement, and talent management.
- Set goals and objectives for case management team and oversees case management data and reporting metrics to achieve quality and cost-effective healthcare results and working with senior leadership, as required.
- Oversight of the development and implementation of case management policies and procedures within the case management team to ensure compliance with regulatory requirements for federal, state, and National Committee for Quality Assurance (NCQA) standards, as required.
- Stays up to date on latest trends and best practices in Payer Care Management and related fields and attends conferences, as required.
- Leads process improvements for the case management team to achieve quality and cost-effective healthcare results and working with senior leadership, as required.
- Contributes to the development and improvement of clinical care pathways that enhance cost effectiveness while providing quality care.
- Develops case management strategies and influences decisions by providing recommendations that align to organizational objectives.
- Develops department budget while collaborating inter-departmentally and with senior leadership.
- Knowledgeable of key requirements (contractual, regulatory, accreditation) related to behavioral health services and the reference materials supporting these.
- Ensuring all P&P's required are kept up to date, accurate and meeting requirements.
- Monitoring and publishing performance measures and comparing and sharing results against requirements or other established benchmarks.
- Collaborates with other health plans and MQD to ensure the bidirectional enhanced referral process supports behavioral health integration.
- Monitoring follow-ups and shared information and treatment planning communications between providers to ensure the process supports improved access to services as well as improved health outcomes.
- Monitoring behavioral health service utilization to ensure that treatment is provided at the least restrictive level of care that supports quality outcomes.
- Implementing changes in the referral process when necessary to support improved access to behavioral health services
- Is responsible for creating a three-year strategic plan and related annual work plan that is aligned with the Health Services Division goals and organizational-wide strategy.
- Is responsible for completion, validation, and timely submission of all required Behavioral Health reports based on the plan's contractual obligations to the State/MQD, CMS, and any accreditation of body/entity (e.g., NCQA).
- Maintains an intentional awareness and executive knowledge of other departments in the Health Services Division, including population health, medical management (Utilization Management), health coordination, and medical directorship.
- Assumes a proactive role in improving the capacity and quality of AlohaCare's -Behavioral Health providers, collaborating with Provider Operations.
- Is responsible for the CCS Behavioral Health-related Quality Improvement process that impacts Medicare Star Ratings, Medicaid Quality Ratings, Pay-For-Performance program, and Auto-Assignment of new but unassigned eligible members.
- Strives toward quality of care and services provided to the members in a timely manner. This includes monitoring processes and documentation as well as identifying and researching potential quality of care issues and forwarding information to the Quality Improvement Department.
- Is accountable for working toward reducing low-value behavioral health services and supporting cost-effective behavioral health services.
- Participate in the budget-making process, following Finance Department guidelines, and monitor budgeted expenses throughout the year, addressing unfavorable material variances.
- Is a contributing member of the AlohaCare Executive Council, prepared to share relevant information or pose timely issues that impact members and Behavioral Health providers.
- Monitor/Coordinate activities with the other AlohaCare Departments and primary care and behavioral health providers (e.g. QUEST Integrated activities) to support behavioral health integration in the primary care setting and the Stepped Care approach. This can include providing training on nationally recognized behavioral health screening tools such as the PHQ-9, or on processes such as SBIRT.
- Facilitate the establishment of Care Compacts between primary care and behavioral health providers to support enhanced regional referrals.
- Has oversight and monitors referrals to specialized programs, such as the Child & Adolescent Mental Health Division (CAMHD) for SEBD services, and AMHD/HSH.
- Triages and coordinates resolution of BH escalated issues as requested by MQD and/or Senior Director.
- Participates in appropriate MQD workgroups.
- Provides consultation, education, and oversight of training to primary care and behavioral health providers as well as care and service coordination teams.
- Provides consultation, education, and training to providers in conjunction with AlohaCare's Provider Network Development Department and AlohaCare's Behavioral Health Manager.
- Identifies and develops community and other resources available to assist providers with members• behavioral health needs.
- Participate in regional community team meetings with primary care and behavioral health providers supporting community coalitions to increase/improve the promotion of the network of behavioral health services available to AlohaCare members, as well as promoting behavioral health integration in the primary care setting.
- Ensure behavioral health representation at the Inter-disciplinary department team meetings or Inter-disciplinary care team meetings with external providers, as well as other ad-hoc meetings.
- Participates and provides updates on the Stepped Care approach outcomes in CQIC (Corporate Quality Improvement Committee) meetings.
- Participates in standing or ad hoc committees, such as the Practitioners Advisory Committee and Utilization Management and Review Committee.
- Participate in organizational workgroups or coordinates BH representation by other BH staff, as appropriate.
- Develop and support Peer Support training and certification.
- Is strategic in directing the Behavioral Health team to participate with accountability in community-based activities, conferences, and initiatives.
- Promote and support the integration of Behavioral Health within and without the Health Services Division in terms of common goals, priorities, workflows, and inter-departmental teamwork.
- Develop all members of the Behavioral Health team as engaged effective leaders and followers.
- Work closely with Human Resources in planning, recruiting, choosing, hiring new staff, ensuring a formal on-boarding process.
- Support internal and external Care and Service Coordination teams and providers in accordance with AlohaCare's policies and procedures emphasizing the importance of staff health and safety and whole person care.
- Development of Case Manager and staff through coaching, mentoring, training, providing opportunities for continuous development, retaining talented individuals.
- Delegate responsibility with its accountability to empower staff.
- Allow for disagreement and conflict, fostering the values of teamwork and resolution that enhances the staff and department to be successful.
- Train internal and external teams in self-management of performance to encourage growth, participation, and achievement.
- Recognize individual or group accomplishments.
- In conjunction with Care and Service Coordination Directors, and with providers• address undesirable individual or group behaviors that require disciplinary action, collaborating with Human Resources
- Monitor work schedules of on and off-site staff, based on rules of fairness, customer service, PTO, tele-commuting.
- Communicate with internal and external teams, continuously, through a variety of modes or venues, including regular team meetings and regular 1:1 meeting with Case Manager
- Develop the overall strategy for onboarding, hiring, and training new case management team members to ensure adequate training and high quality-care to improve member and/or provider experience and ensure compliance.
- Demonstrate leadership attributes such as active listening, defining issues, resolving conflict, being facilitative, inspiring staff, empowering staff, and training the trainers.
- All other duties assigned.
- Adhere to regulatory compliance and quality guidelines as well as AlohaCare policies and procedures.
- Responsible for maintaining AlohaCare's confidential information in accordance with AlohaCare policies, and state and federal laws, rules, and regulations regarding confidentiality. Employees have access to AlohaCare data based on the data classification assigned to this job title.
Requirements: - Bachelor's degree in public health, health administration, nursing, social work, or a related field or equivalent combination of education and experience.
- Clinical licensure meeting the requirements for Qualified Mental Health Professional (QMHP), LCSW, LMHC, LMFT or Psychologist in the State of Hawaii.
- Physician, psychologist, registered nurse, or licensed clinical social worker licensed in the State of Hawaii with experience related to the behavioral health population.
- Minimum of 5 years of experience in Medicaid and/or Medicare programs.
- Minimum of 5 years of experience working with consumers of behavioral health services and providers.
- Minimum of 3 years of experience in managed care and/or care management .
- Minimum of 5 years of experience managing and developing a team.
- Minimum of 3 years of experience in multiple health services operational areas (see list in responsibilities section).
- Clinical program development and implementation experience.
- Strong knowledge of community resources including specialty care, behavioral health care resources, inpatient, and outpatient community resources.
- Managing and overseeing health services operations including Directors, Managers, Supervisors, and staff.
- Cost of care and budget accountability (MLR, P+L, SG&A).
- Demonstrated track record of participation in audits and compliance programs.
- Working knowledge of State and Federal policy initiatives that relate to health services.
- Experience in quality improvement programs.
- Experience in applying PDSA methodology or other systematic critical thinking approaches.
- Achieves results, builds trust, communicate effectively, customer and quality focused.
- Excellent interpersonal skills with the ability to communicate with all levels of the organization.
- Strong interpersonal, facilitation and leadership skills with ability to interact with various departments/ project teams.
- Excellent, effective, and precise written and oral communication skills; speak clearly and persuasively in positive or negative situations.
- Ability to organize, coordinate and supervise large projects in a timely, creative, and effective manner.
- Ability to solve problems, analyze, think critically, make good judgment, and make fair decisions.
- Experience in p
