- This role will involve up to 40% Travel across AbsoluteCare locations
- RN license preferred.
- Certification in Case Management (CCM), Utilization Review Accreditation Commission (URAC), or related credentials is a plus.
Job Summary This Senior Director role over Complex Care Management (CCM) and Utilization Management (UM) is a strategic senior leader position that is responsible for designing, implementing, and optimizing integrated care delivery models that improve health outcomes for medically and socially complex populations. This role oversees the national CCM and UM programs, ensuring alignment with at-risk value-based care principles, transitional care management, regulatory compliance, and operational excellence across all markets. Experience with delegated care management and/or utilization management from a health plan is a major plus.
Duties and Responsibilities Program Oversight - Direct the implementation of high-intensity, member-centered care models that reduce avoidable utilization and improve quality of life.
- Leads conversations with medical economics on understanding the financial impacts of both care management and utilization management programs.
- Supports the build of useful daily management reports to help support local managers in managing their team's productivity and effectiveness.
- Develops materials and leads a monthly overview meeting for key executives to talk about strategic direction of both CCM and UM programs and executes on the strategy.
- Ensure compliance with NCQA standards and other regulatory requirements for UM and care coordination services. - Supervises, leads a CM Program Manager, TCM program lead , two Clinical Educators, and three centralized Community Team Care Managers (total of 4-7 direct reports).
Operational Excellence - Monitor and optimize care and utilization management workflows, staffing models, and performance metrics across CM and UM teams including bed management, admissions, and ED utilization.
- Lead the development of efficient and effective clinical training programs, documentation standards, policies and procedures and performance management systems to support clinical and non-clinical staff.
Team Development - Build and mentor a high-performing interdisciplinary team including care managers, behavioral health clinicians, UM nurses, and community health workers.
- Foster a culture of accountability, innovation, and continuous improvement. - Responsible for working with site leaders to develop and implement clinical engagement/retention action plans that enhance staff satisfaction survey results
Stakeholder Engagement - Serve as a key liaison with payer and health system hospital partners, regulatory bodies, and internal stakeholders to ensure transparency, compliance, and shared success.
- -Develop strong working relationships with market UM/CM leaders, engagement leaders and VPs that influence optimal clinical engagement AND clinical model execution.
- Represent the organization in strategic discussions with external partners and at industry forums.
Minimum Qualifications - Bachelor's degree in Nursing, Public Health, Health Administration, or related field required; Master's degree preferred.
- Minimum of 7-10 years in a Senior Director or Vice President role overseeing complex care management, transitional care management or utilization management in a managed care or at-risk value-based medical group environment.
- Proven track record of leading large-scale, multi-site clinical operations, driving cost savings, achieving affordability targets and improving patient outcomes.
- Deep understanding of Medicaid/Medicare populations, transitional care management leading to readmission reduction, , and integrated care delivery models.
- Strong leadership, communication, and change-management skills. - Knowledge and experience working with ZeOmega/Jiva electronic health record is a plus, but not required.
- Must be willing to travel across our different markets to interact with corporate leadership team, managers, and front-line staff.
Preferred Certifications - RN license preferred.
- Certification in Case Management (CCM), Utilization Review Accreditation Commission (URAC), or related credentials is a plus.
Working conditions This job operates in a remote location from your home location. This role requires a dedicated, quiet workspace with the ability to adhere to HIPAA and other privacy policies. A reliable and high-speed Wi-Fi connection or home internet is required to perform the essential functions of this role.
Physical requirements - Ability to communicate clearly and exchange accurate information constantly.
- Ability to remain stationary for long periods of time.
- Repetitious movements.
- Constantly operates computer, keyboard, copy and fax machine, phone, and other general office equipment
Direct reports Care Management Program (lead) Manager, Transitional Care Manager Program (Lead) Manager, Centralized CCM, Clinical Educator
