Sr Mgr, Field Health Services-St. Louis-MO

Senior, Manager Field Health Services-St. Louis-MO:
Manages the daily activities of the Field Health Services team. Develops and manages provider partnerships to achieve quality and cost management objectives. Works with the Market Medical Director, Contracting and Provider Relations departments coordinating, monitoring, evaluating services and outcomes (clinical and financial) to maximize the healthcare of the member and service to our provider partners. Develops and maintains a working relationship with the client.

Reports to: VP, Field Health Services

Department: Health Services

Position Location: St. Louis, Columbia, or Springfield MO

Essential Functions:
  • Develops, with the Medical Director, departmental and team member goals and meets with team members on periodic basis to review and assess associate’s performance.
  • Oversees the implementation of programs and strategies.
  • Accountable for all monthly and quarterly client reports regarding utilization, case and disease management. Ensure timeliness and accuracy of the reports for Medical Director review and approval.
  • Serves as a conduit for communication between the client and the company. Works to resolve issues related to members, providers and any WellCare utilization process.
  • Oversees the utilization management-medical advisory committee (UMAC) each quarter, all agenda, materials and communication with external/internal presenters. Accuracy of meeting minutes and providing to the quality improvement committee timely.
  • Partners and collaborates with other departments cross functionally to provide all necessary documents for NCQA and/or ERQO and to participate in audits as needed.
  • Coordinates department projects and activities to meet budget figures and appropriate deadlines.
  • Creates, disseminates and communicates daily, weekly and monthly data and information summaries to both team members and senior management for review.
  • Proactively monitors appropriate metrics to drive up efficiency.
  • Manages process improvement initiatives; develops and implements workflows and policies & procedures.
  • Monitors work flow processes and outcomes to ensure business goals are met.
  • Manages and develops direct reports who include supervisory and/or exempt professional personnel including but not limited to hiring, focal point reviews, PIP, terminations, etc.
  • Partners & collaborates with other departments cross functionally regarding Health Service initiatives and serves as a representative for Health Services on interdepartmental initiatives.
  • Provides guidance on issues related to clinical practice, authorization process, benefits and other utilization management issues.
  • Effectively communicates with internal/external customers to provide information, resolve issues and promote a positive relationship between departments, providers and members.
  • May develop and manage provider partnerships to achieve quality and cost management objectives (IPA groups, ancillary providers, etc).
  • Serves as a conduit for communication between corporate teams, market teams and providers on issues related to Utilization Management.
  • Performs special projects as needed.
Education: RN required. A Bachelor's Degree in Nursing or Health Administration preferred.
Experience: 7 years’ current case or utilization management experience with experience in ER/critical care, discharge planning and bedside care. 5 years in managed care and at least 3 years’ management/supervisory experience.
Licenses/Certifications: Current RN state licensure required. Professional certification (such as CCM or CPHQ) preferred.
Special Skills (e.g. 2nd language):
Strong clinical knowledge of broad range of medical practice specialties.
Ability to create, review and interpret treatment plans.
Knowledge of Utilization Management principles and criteria sets such as InterQual, Medicare guidelines, etc.
Ability to lead and manage others; may be required to manage a team in a metrics driven environment.
Demonstrated negotiation skills
Demonstrated ability in problem solving and communication
Previous experience working with treatment teams to meet the healthcare needs of participants
Knowledge of community, state and federal laws and resources
Strong oral and written communication skills including the ability to effectively present information and respond to questions from families, members, and providers as well as the ability to relate effectively to upper management.
Ability to work independently, handle multiple assignments, establish priorities, and demonstrate high level time management skills.
Technical Skills/Requirements:
Proficiency in Microsoft Office including Outlook, Word and Excel; knowledge of Access and/or Visio preferred.
Knowledge of or the ability to learn company approved software such as CRMS, Peradigm, InterQual, Sidewinder and other software in order to perform job duties.

About us
Headquartered in Tampa, Fla., WellCare Health Plans, Inc. (NYSE: WCG) focuses primarily on providing government-sponsored managed care services to families, children, seniors and individuals with complex medical needs primarily through Medicaid, Medicare Advantage and Medicare Prescription Drug Plans, as well as individuals in the Health Insurance Marketplace. WellCare serves approximately 5.5 million members nationwide as of September 30, 2018. WellCare is a Fortune 500 company that employs nearly 12,000 associates across the country and was ranked a "World's Most Admired Company" in 2018 by Fortune magazine. For more information about WellCare, please visit the company's website at EOE: All qualified applicants shall receive consideration for employment without regard to race, color, religion, creed, age, sex, pregnancy, veteran status, marital status, sexual orientation, gender identity or expression, national origin, ancestry, disability, genetic information, childbirth or related medical condition or other legally protected basis protected by applicable federal or state law except where a bona fide occupational qualification applies. Comprehensive Health Management, Inc. is an equal opportunity employer, M/F/D/V/SO.