Develop, implement, support, and promote Health Services strategies, tactics, policies, and programs that drive the delivery of quality healthcare to establish competitive business advantage for the plan. Health Services strategies, policies, and programs are comprised of utilization management, quality management, network management and clinical coverage and policies. Focuses on integrating member care, clinical coordination, leading the development, implementation and ongoing monitoring of program and quality initiatives to address the needs of members. Represents the plan and collaborates with State governments, key stakeholders, community organizations, advocacy groups as well as the Medical Director and leadership team to enhance the quality of services provided to members and to ensure adherence to performance targets of the business area.
DEPARTMENT: Health Services-Behavioral Health
REPORTS TO: Behavioral Health Medical Director
- Partners with Plan executive leadership team to provide overall vision and leadership across all Plan activities. Serves as a key resource regarding any issues related to the integration of behavioral health member care across departments.
- Consults with Plan executive management regarding physical and behavioral health clinical issues as they relate to medical management (UM, CM, DM) provider and system of care issues, behavioral health and human services system issues including critical stakeholders such as various departments of state government, provider organizations, advocacy organizations, etc.
- Partners with BH Medical Director to manage and oversee ICM within the health plan. Provides consultation to support physicians at other Medicaid Plans.
- Participates in organizational planning, including strategic plans, business plans, and new product development.
- Solicits staff input related to their job functions and leverages errors and failure to reach performance targets as opportunities for organizational learning and improvement.
- Supports and encourages CM, UM and DM staff to function as interdisciplinary team, with requisite range and depth of subject matter expertise to meet the needs of the covered population.
- Represents Plan to relevant external stakeholders, such as state government officials, providers/vendors, & advocacy groups with regard to quality improvement initiatives, integrating member care, health plan success, and innovative care strategies.
- With the plan's physician leader, co-facilitates interdisciplinary case rounds to address the needs of members with complex clinical presentations, identifies opportunities for improving rounds, and works with the clinical leadership team to optimize the value of rounds to the clinical staff.
- Demonstrates knowledge about established and evolving biomedical, clinical, epidemiologic and social-behavioral sciences and the application of this knowledge to member care.
- Participate in and support process improvement initiatives within care management and across broader Plan operations.
- Performs other duties as assigned.
- Required A Master's Degree in Social Work
- Required 3 years of experience in complex case work experience, perferably in managed care environment in a community or institutional setting
- Required 4 years of experience in a clinical setting
- Required 4 years of experience in a managed care setting
- Required Other Experience in handling mental health and psychiatric care, family situations, relationship concerns
- Required Other Experience working with managed and non-managed health care benefits
- Required Other Experience with third party relationships, including local community building efforts, governmental and regulatory authorities
Licenses and Certifications:
- Intermediate Ability to analyze information and covert related activities into a comprehensive work plan
- Intermediate Ability to communicate and make recommendations to upper management
- Intermediate Ability to create, review and interpret treatment plans
- Intermediate Ability to drive multiple projects
- Intermediate Ability to effectively present information and respond to questions from families, members, and providers
- Intermediate Ability to effectively present information and respond to questions from peers and management
- Intermediate Ability to implement process improvements
- Intermediate Ability to represent the company with external constituents
- Intermediate Demonstrated customer service skills
- Intermediate Demonstrated interpersonal/verbal communication skills
- Intermediate Demonstrated written communication skills
- Intermediate Knowledge of community, state and federal laws and resources
- Intermediate Knowledge of healthcare delivery
- Required Licensed in one of the following: