Base Compensation Range: $132,700 - $153,700
Compensation & Benefits - Competitive cash compensation
- Comprehensive health plans
- Generous PTO
- Future focused 401k match
POSITION SUMMARYThe Medical Management Director role involves overseeing and enhancing our care management programs, utilization management processes, and appeals operations. The ideal candidate will bring a strategic vision and leadership to ensure high-quality, cost-effective care and compliance with regulatory requirements.
ESSENTIAL FUNCTIONS AND RESPONSIBILITIESLeadership and Strategy:- Develop and implement strategic plans for care management, utilization management, and appeals programs.
- Lead and mentor a team of professionals in these areas, fostering a culture of excellence and continuous improvement.
- Collaborate with senior leadership to align departmental goals with the organization's overall mission and objectives.
- Under the oversight of the CMO, manages budget for programs as well as care model
Care Management:- Oversee the development and execution of care management programs to enhance member outcomes and satisfaction and reduce total costs of care.
- Ensure the Care Management is integrated into CHOs population health strategy
- Monitor and evaluate care management performance metrics and implement strategies for improvement.
Utilization Management:- Manage utilization review processes to ensure appropriate use of resources and adherence to clinical guidelines.
- Develop policies and procedures for utilization management that comply with regulatory standards and payer requirements.
- Analyze utilization data to identify trends and opportunities for cost savings and quality improvement.
Appeals Management:- Oversight of the appeals process to ensure timely and accurate handling of denials and appeals.
- Develop and maintain policies and procedures for appeals management, ensuring compliance with regulatory and contractual requirements.
- Collaborate with clinical and operational teams to resolve complex cases and improve the appeals process.
- Oversight of Appeals Vendor contracts.
Quality and Compliance:- Ensure all programs comply with federal, state, and local regulations, as well as accreditation standards.
- Implement quality improvement initiatives to enhance the effectiveness and efficiency of care management, utilization management, and appeals processes.
- Stay abreast of industry trends and best practices to maintain a competitive edge.
Collaboration and Communication:- Work closely with internal and external stakeholders, including healthcare providers, payers, and regulatory agencies, to optimize care delivery and resource utilization.
- Foster strong communication and collaboration among multidisciplinary teams to support integrated care management and utilization management efforts.
JOB SPECIFIC KEY COMPETENCIES (KSAs)- Ability to adapt and be nimble to effectively problem-solve complex, multifaceted, and/or emotionally charged situations.
- Advanced Skills in Microsoft Products and adaptability to electronic documentation system.
- Excellent communication, writing, analytical and problem-solving skills.
QUALIFICATIONS AND CORE REQUIREMENTS- Bachelor's Degree in related health field, preferred.
- Minimum of 2-3 years of Health Plan Medical Management (Utilization Management and Appeals) experience.
- Leadership experience with working knowledge of human resource principles that promote a positive working environment and adherence to applicable regulatory requirements
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