Field Health Services - Senior Director

WellCare Health Plans   •  

Phoenix, AZ

Industry: Healthcare

  •  

8 - 10 years

Posted 33 days ago

Essential Functions:

  • Develops and implements the quality improvement plan within regional markets in accordance with the mission and strategic goals of the organization, federal and state laws and regulations, and accreditation standards.
  • Establishes professional relationships with state, stakeholders and community agencies to facilitate quality processes internally and externally for QI, CM, and UM.
  • Analyzes, updates, and modifies standard operating procedures and processes to continually improve QI Department services/operations.
  • Manages and develops direct reports who include other management or supervisory personnel and/or individual case managers who have clinical expertise and are trained in Case Management activities.
  • Plans, conducts and directs work on complex projects/programs necessitating the origination and application of new and unique approaches for QI, CM, and UM.
  • Establishes budget, obtains approval from senior management and monitor for adherence. Links budgetary expenses to define improvements in member health and/or cost savings.
  • Manages and develops direct reports who include other management or supervisory personnel and/or individual case managers who have clinical expertise and are trained in QI, CM, and UM.
  • Directs the review of assessments by nurse managers and provides advice in regard to complex, controversial or unique administrative processes, medical procedures and payment guidelines.
  • Develops strategies for special program participation and Quality Improvement. Develops systems for close coordination of QI related functions with departments whose activities are directly a part of the QI Program, including Credentialing.
  • Collaborates with Health Services, Operations, and Information Technology departments to ensure full integration of quality improvement reporting for contract and accreditation compliance.
  • Establishes professional working relationships with all providers towards the end goal of establishing a care continuum for the members.
  • Leads a continuous improvement of the WellCare Case Management process by developing and disseminating best practices throughout the enterprise.
  • Educates WellCare departments on the Case Management Programs, especially in regard to identification of potential cases.
  • Maintain collaboration with Inpatient Services, Outpatient Services, Pharmacy, Customer Services and Quality Improvement to ensure early identification of members in need of Case Management.
  • Ensures compliance with all state and federal regulations and guidelines for all lines of business in all States.
  • Participates in site visit preparation and execution by regulatory and accreditation agencies (state agencies, URAC,NCQA,CMS,AAAHC,EQRO)
  • Performs special projects as assigned.

Additional Responsibilities: Candidate Education:

  • Required A Bachelor's Degree in Nursing or Health Administration or directly related field
  • Required or equivalent work experience 10 years direct leadership experience in Utilization Management, Case Management and/or Quality Improvement in a managed care environment.
  • Preferred A Master's Degree in Business Administration, Public Health, Health Administration or related field

Candidate Experience:

  • Required 10 years of experience in Directly related Quality Improvement job duties, Case Management, and Utilization Management
  • Required 5 years of experience in Managed healthcare
  • Required 5 years of experience in working with JCAHO, URAC, AAAHC, and the NCQA standards

Candidate Skills:

  • Intermediate Ability to create, review and interpret treatment plans
  • Intermediate Ability to implement process improvements
  • Intermediate Ability to lead/manage others in a matrixed environment
  • Intermediate Demonstrated interpersonal/verbal communication skills
  • Intermediate Demonstrated leadership skills
  • Advanced Ability to effectively present information and respond to questions from families, members, and providers
  • Advanced Ability to influence internal and external constituents
  • Advanced Ability to communicate and make recommendations to upper management
  • Advanced Ability to influence internal and external constituents
  • Advanced Knowledge of healthcare delivery

Licenses and Certifications:
A license in one of the following is required:

  • Required Licensed Registered Nurse (RN)
  • Preferred Certified Case Manager (CCM)

Technical Skills:

  • Required Intermediate Microsoft Word
  • Required Intermediate Microsoft Outlook
  • Required Intermediate Healthcare Management Systems (Generic)
  • Required Intermediate Microsoft Excel

Job Number: 1805027