Director of Care management Coordination and Utilization Management

Humana   •  

Houston, TX

Industry: Healthcare

  •  

5 - 7 years

Posted 59 days ago

This job is no longer available.

Description

The Director, Health Services utilizes clinical nursing skills to support the coordination, documentation and communication of medical services and/or benefit administration determinations. The Director, Health Services requires an in-depth understanding of how organization capabilities interrelate across the function or segment. Be a part of the Clinical Space. As the Director of Care management Coordination and Utilization Management, you will be required to have a broad understanding of level of care environments including acute hospitals, post- acute facilities, home health, DME, outpatient services, and managed care clinic operations. Accountable for utilization management activities as well as care transition workflows and care management workflows. Individual should be well versed in caretranitionstransitionsand Care management theory/ models. Individual will design an organizational structure of clinical staff that is capable of achieving organizational goals. Will be responsible for adherence to federal and state compliance regulations for care coordination clinical staff within the clinics and staff within the utilization team framework.

Responsibilities

Be a part of the Clinical Space.  As the Director of Care management Coordination and Utilization Management, you will be required to have a broad understanding of level of care environments including acute hospitals, post- acute facilities, home health, DME, outpatient services, and managed care clinic operations.  Accountable for utilization management activities as well as care transition workflows and care management workflows. Individual should be well versed in care transitions and Care management theory/ models.  Individual will design an organizational structure of clinical staff that is capable of achieving organizational goals.  Will be responsible for adherence to federal and state compliance regulations for care coordination clinical staff within the clinics and staff within the utilization team framework.

Role Competencies:

  • Excellent written and verbal communication skills.  Demonstrate active listening skills; communicate clearly and concisely; ensure understanding regardless of the communication vehicle; understand the needs and perspectives of others with ability to tailor the delivery accordingly; share information appropriately
  • Emotional Maturity as demonstrated by an understanding of oneself to manage emotions; listen to and understand others; able to build trusting relationships with patients, providers, and care team; understand proper use of chain of command and know when and how to escalate.
  • Ability to work independently under general instruction but also understand how to collaborate with a team of all levels
  • Attention to detail with ability to work in a fast paced environment to meet regulatory time frames
  • Responsible for achieving organization goals and metrics; accountable for results of assignment;  take accountability for results
  • Strong organization and time management skills with the ability to prioritize; organize and manage multiple priorities and/or projects using appropriate methodologies and tools
  • Demonstrated ability to create a positive and meaningful patient, provider and care team experience
  • Self –motivated and committed to achieving results
  • Possess critical thinking skills, independent decision making capability
  • Proactively identify, evaluate, and solve problems with logic and a systematic approach; look beyond the obvious to see root cause issues and creative solutions.  Make appropriate decision in the face of ambiguity.  Anticipate and resolves barriers and constraints
  • Flexible to changes in assignments and teams

               

Role Requirements:

  • Broad understanding of level of care environments including acute hospitals, post- acute facilities, home health, DME, outpatient services, managed care clinic operations
  • Successful Management experience leading teams, projects and multiple priorities
  • Experience with managing and negotiating with external customers/vendors
  • Demonstrate strategic thinking and organizational skills that lead to success
  • Ability to appropriately utilize resources, leverage technology for improved efficiency
  • Excellent communication skills. Experience with difficult conversations
  • Demonstrated ability to effectively influence and collaborate with all team/ leadership levels.
  • Demonstrate professional flexibility with scheduling, travel and competing priorities
  • Strong analytical skills, experience with financialreports
  • Successful experience with P&L management
  • Exhibit positive approach to problem solving, motivation and persuasion of others.
  • Knowledge of the managed care industry including Medicare, Medicaid and or Commercial products
  • Medicare Advantage/Medicare/Medicaid utilization management experience
  • Experience and successful oversight of a clinical care management model in an outpatient setting
  • Ability to analyze outcome measures of care management programs and adjust programs to achieve better results
  • Possess analysis and interpretation skills with prior experience leading teams focusing on quality management, utilization management, discharge planning and/or home health or rehab
  • Demonstrate Emotional Maturity
  • Master’s Degree or equivalent experience
  • Five years management experience
  • Active RN license
  • Ability to Travel up to 50%

Preferred Experience & Skills

  • Previous experience in ambulatory care management programs as a care manage/care coach and as a leader
  • Previous experience leading teams focusing on utilization management, discharge planning and/or home health or rehab
  • Medical management experience, working with managed care clinics, health insurance organizations, hospitals and other healthcare providers, patient interaction, etc.
  • Process-oriented, evidence-based and scientifically-inclined
  • Consistent, enjoy being a part of a team, thoughtful and possess a thirst for continuous education and development
  • Experience in utilization management within managed care industry
  • Strong working knowledge of Excel
  • English and Spanish bilingual preferred

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