Position Purpose: Creates clinical programs to meet the needs of members in Care Management. Works closely with Medical Informatics team to identify trends that need to be addressed with program management. Monitors the program work plan to assure attainment of Medical Management annual goals. Responsible for Care Management clinical inter-rater reliability and monitoring important aspects of care. Directs the work of subordinates in dissimilar functions.
- Effectively manages the activities of staff providing leadership and guidance.
- Interviews, recommends for hire, and evaluates staff, and counsels and confronts unsatisfactory performance promptly and fairly and administers corrective action.
- Identifies department goals and objectives, develops and communicates action plans through regular staff meetings and other communications, uses team approach to problem solve and sets clear expectations.
- Identifies training needs and develops and participates in staff training. Provides a challenging and supportive environment and delegates appropriately. Seeks additional training opportunities through outside sources.
- Analyzes work plans developed by subordinate managers and monitors the status of their work in relation to the overall schedule requirements.
- Develops monitoring systems and measurements and exhibits a customer service philosophy.
- Manages statistical and qualitative information concerning patient outcomes and physician/hospital practice patterns in accordance with health plans’ utilization standards.
- Intervenes with hospital or physician contractors to examine cases to ensure methods for meeting these utilization standards while maintaining precedent for quality of case standards.
- Determines and enforces - through functional groups - medical management requirements in accordance with real company needs, based on current regulations and state-of-the art product development.
- Organizes and promotes medical management functions.
- Evaluates and develops improved techniques for the control of quality and reliability.
- Plans and develops improved techniques for the control of health care costs.
- Plans, on a quarterly or longer basis, the overall use of resources.
- Provides information and advice to higher level management related to medical management.
Education/Experience: Bachelor’s degree in Nursing or equivalent required; Master’s degree in Health Services Administration or equivalent desired. Five years clinical experience in an acute care setting. Four years experience in quality management/improvement in a health care setting. Two years work experience in a managed care environment. Five years management experience in a health care setting. Three years medical management experience in an HMO setting desired
License/Certification: Must have and maintain current valid and unrestricted Registered Nursing (RN) license. Valid state driver’s licen