Position Purpose: Direct medical management program including utilization management, case management, quality improvement and credentialing in accordance with the mission, philosophy, and objectives of plan and in conjunction with Corporate goals and objectives.
- Develop department objectives and organize activities to achieve objectives.
- Evaluate and implement changes to medical service functions and performance in relation to company mission, philosophy objectives and policies.
- Manage budget and forecast for strategic planning and key initiatives.
- Coordinate with operating departments on research and implementation of best practices.
- Responsible for the statistical analysis of utilization data on programs.
- Participate in NCQA, State, and/or other accreditations of the Plan.
- Organize and present new concepts, programs and tools to staff and other plan departments.
- Develop communication plans with external providers such as hospitals and State agencies as required to facilitate plan goals and objectives.
- Coordinate with Medical Director to educate and communicate expectations with providers.
Education/Experience: Bachelor's degree in Nursing, related field, or equivalent experience. 7+ years of nursing, quality improvement, and management experience in a healthcare environment, preferable managed care. Previous management experience including responsibilities for hiring, training, assigning work and managing performance of staff.
License/Certification: RN license.