Manages the daily activities of the Field Health Services team comprised of prior authorization, concurrent review, utilization management and case management. Develops and manages provider partnerships to achieve quality and cost management objectives. Works with the Market Medical Director, contracting and provider relations departments coordinating, monitoring and evaluating services and outcomes (clinical and financial) to maximize the healthcare of the member and service to our provider partners.
Reports to: VP Clinical Management
Department: Health Services
Location: Omaha, Nebraska
- Develops, along with the Medical Director, departmental and team member goals and meets with team members on a periodic basis to review and assess associate's performance.
- Oversees the implementation of clinical programs and strategies.
- Accountable for all monthly and quarterly client reports regarding utilization review and case and disease management. Ensures timeliness and accuracy of the reports for Medical Director review and approval.
- Serves as a conduit for communication between the client and the company. Works to resolve issues related to members, providers and any WellCare utilization review or case/disease management process.
- Oversees the utilization management-medical advisory committee (UMAC) each quarter along with all agenda, materials and communication with external/internal presenters. Ensures accuracy of meeting minutes and provides to the quality improvement committee timely.
- Partners and collaborates with other departments cross functionally to provide all necessary documents for NCQA and/or state quality reviews and to participate in audits as needed.
- Coordinates department projects and activities to meet budget figures and appropriate deadlines.
- Creates, disseminates and communicates daily, weekly and monthly data and information summaries toboth team members and senior management for review.
- Proactively monitors appropriate metrics to drive up efficiency.
- Manages process improvement initiatives, develops and implements workflows and develops policies & procedures.
- Monitors work flow processes and outcomes to ensure business goals are met.
- Manages and develops direct reports who include supervisory and/or exempt professional personnel including but not limited to hiring, focal point reviews, PIP, terminations, etc.
- Partners and collaborates with other departments cross functionally regarding Health Service initiatives and serves as a representative for Health Services on interdepartmental teams.
- Provides guidance on issues related to clinical practice, authorization process, benefits and other utilization and case management issues.
- Effectively communicates with internal/external customers to provide information, resolve issues and promote a positive relationship between departments, providers and members.
- May develop and manage provider partnerships to achieve quality and cost management objectives (IPA groups, ancillary providers, etc).
- Serves as a conduit for communication between corporate teams, market teams and providers on issues related to utilization and case management.
- Performs special projects as needed.
- Required A Bachelor's Degree in nursing, public health, business administration or related field or equivalent work experience
- Candidate Experience:Required 10 years of experience in current case or utilization management experience with experience in ER/critical care, discharge planning and bedside care
- Required 4 years of management experience
- Required 5 years of experience in managed care
- Required Other For NC Medicaid Contract, candidates must possess 5 years ofdemonstrated care management /population health experience in a large healthcare corporation serving Medicaid beneficiaries as a NC licensed clinician (e.g. LCSW, RN, MD, DO)
- Candidate Skills:Advanced Ability to create, review and interpret treatment plans
- Intermediate Demonstrated negotiation skills
- Advanced Ability to lead/manage others
- Advanced Demonstrated problem solving skills
- Advanced Demonstrated interpersonal/verbal communication skills
- Advanced Knowledge of community, state and federal laws and resources
- Advanced Demonstrated written communication skills
- Advanced Ability to effectively present information and respond to questions from families, members, and providers
- Advanced Ability to effectively present information and respond to questions from peers and management
- Advanced Ability to work independently
- Advanced Demonstrated time management and priority setting skills
- Advanced Ability to multi-task
- Advanced Knowledge of healthcare delivery
- Advanced Other Knowledge of utilization and case management principles and criteria sets such as InterQual, Medicare guidelines, etc
- Advanced Other Previous experience working with treatment teams to meet thehealthcare needs of participants
- Advanced Other Strong clinical knowledge of broad range of medical practice specialties
Licenses and Certifications:
A license in one of the following is required:
- Required Licensed Registered Nurse (RN)
- Preferred Certified Case Manager (CCM)
- Preferred Certified Professional in Healthcare Quality (CPHQ)
- Technical Skills:Required Intermediate Microsoft Outlook
- Required Intermediate Microsoft Word
- Required Intermediate Microsoft Excel
- Preferred Intermediate Microsoft Access
- Preferred Intermediate Microsoft Visio
- Required Intermediate Healthcare Management Systems (Generic)