The Director of Care Management for Health Plans is responsible for leading and implementing care and disease management programs for SSM Health Plans, including common chronic conditions, complex case management, prevention and wellness, and programs designed to address the needs of under-served or high-cost claimants. This clinical leader recognizes opportunities for program enhancement and new program development to best identify and impact member populations to improve health outcomes, advance quality metrics, manage medical expense, collaborate effectively with providers, meet account and other strategic stakeholder demands, ensure compliance with regulatory and accreditation requirements, and ensure effective and efficient use of resources. Working with the support of other leaders in and external to Health Services, the Director utilizes reliable methods for measure and evaluate the effectiveness of these programs in terms of quality, medical cost reduction as well as appropriate utilization. The Director creatively deploys clinical and other resources to flexibly meet the evolving needs of members, providers, employer groups, and the health plan, as geographic, network and product expansion develop. This Director is a member of the Health Services leadership team and works to ensure effective communication and coordination among Care Management, Utilization Management, Pharmacy Services and Quality in support of the unit’s strategic goals. The Director will mentor and develop staff and will foster a positive and effective working relationship with key external and internal customers.
1. Develops, implements and continually improves care management, disease management and population health management programs for all SSM Health Plans including, but not limited to: DHP, SHP, Prevea360 and the SSM Employee Health Plan.
2. Develops and maintains policies, procedures and standards for all channels of care management services in support of internal business goals and external regulatory requirements.
3. Works collaboratively with IDN leadership in all geographies to create value through CM services, chiefly through demonstrated delegation arrangement oversight.
4. Works directly with network practices in all geographies to provide full service CM value through the Plan such as through P4P arrangements. Motivates and aligns providers to achieve value.
5. Uses clinical acumen, current industry research, trends and benchmarking to develop new approaches to improve health outcomes for members, creatively and flexibly collaborate with providers, and meet product and market demands.
6. Employs extensive knowledge base to evaluate provider capabilities in the areas of care and disease management and recommend collaborative approaches that best support SSM Health Plans’ strategic goals and provide opportunities for provider success.
7. Working collaboratively with other areas within the division and Plans, develops referral rules and hand-offs that most appropriately engage members to improve outcomes, manage costs, and enhance member experience.
8. In-depth knowledge of and ability to use analytics to demonstrate outcomes in quality and medical cost, and drive market-based solutions across multiple settings, markets, and geographies.
9. Works with other leaders to establish rigorous methodologies for measuring program impact on quality, medical cost, and utilization and achieves results.
10. Uses these methods, as well as others such as budget adherence, member satisfaction, and account retention, to monitor and evaluate program value and effectiveness.
11. Includes key success measures in established reporting dashboards for monitoring and evaluation by senior leadership.
12. Works with appropriate analytical and technical subject matter experts to create algorithms and/or other methods to identify populations and interventions that will drive improved quality and cost outcomes.
13. Identifies barriers to success of programs and works closely with other leaders within Health Services and other departments to develop and implement plans to improve approaches and/or overcome obstacles to improvement.
14. Determines appropriate resource allocation for care and disease management programs and initiatives to maximize quality, efficiency and cost-effectiveness while adhering to corporate budget mandates.
15. Recruits, selects, and evaluates performance of professional and nonprofessional staff.
16. Uses effective performance management techniques to promote staff engagement, development, growth and success.
17. Directs the effective use of existing care management systems and tools to manage programs, outreach, and department workflows and efficiency.
18. Provides critical input into care management system upgrades and/or new system selection and implementation as needed, ensuring functionality best automates and supports appropriate clinical assessment, documentation, operations management, service and data integration, and the reporting and analytics needs of Care Management and in support of other Health Services functions, as well as providers, accounts and other key stakeholders.
19. Communicates with, and presents audience-appropriate information to, internal and external stakeholders in order to enhance their understanding of, and/or role in, SSM Health Plans’ Care Management programs.
20. Plays a key role in clinical program-specific build/buy decision-making, and vendor relations as needed.
21. Has department budget development and fiscal management responsibility.
1. Active professional health care license with post-graduate degree in healthcare. RN/NP preferred.
2. At least 7 years of experience in healthcare including in delivery system and insurance industry
3. At least 5 years of progressive leadership and management responsibilities in health plan CM, with minimum 2 years at Director level.
4. Deep experience developing and leading multi-faceted population health management programs for all products, with demonstrated ROI, including disease management, care coordination, case management, quality, and NCQA accreditation.
5. Experience with new market and product growth and development.
6. Demonstrated skill in complex relationships and demonstrating value with providers, employers, and health care communities
7. Demonstrated ability to respond with creative solutions and flexibility as the environment and organization change
8. Demonstrated ability to problem solve, exhibiting sound judgement and a realistic understanding of issues, and to motivate individuals and groups
1. Multistate oversight experience.