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Clinical Care Management - Senior Director Job

Full Job Title: Sr Dir, Clinical Care Management

Job Number: 1704713

Tampa, FL
Brentwood, TN
Houston, TX
Phoenix, AZ

Date Posted: 11-6-2017

Develops core curriculum plans, assigns resources and direct activities for the Case Management program enterprise wide. Assesses the effectiveness of programs in achieving enterprise goals with focus on cost-effective improvement in quality of care for members. Oversee productivity of Case Management associates and drive results and outcomes of the Case Management programs.

Reports to: HS-VP, Clinical Management

Department: Health Services

Location: Texas, Florida, Arizona, Tennessee

Essential Functions:

  • Researches, interprets and integrates pertinent medical literature to develop cost effective Case Management programs with measurable results.
  • Plans, conducts and directs work on complex projects/programs necessitating the origination and application of new and unique approaches.
  • Communicates with management at the highest level to ensure adequate budgetary allocation of staff and other resources.
  • Communicates with external customers including but not limited to Federal and State Program Directors, legislators, government executives and physician partners.
  • Establishes budget, obtains approval from senior management and monitor for adherence. Links budgetary expenses to define improvements in member health and/or cost savings.
  • Ensures corporate initiatives are implemented to achieve optimum results.
  • 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.
  • 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 and ensures maximum efficiencies in the utilization of human and financial resources.
  • Sets operational priorities and manages resources to operational goals and budgets.
  • 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.
  • Works with Medical Directors to tap their expertise in the management of members.
  • Responsible for oversight of the design of non-existing medical management programs, such as for the ID/DD population.
  • Responsible for oversight of the Medical Management's contributions to RFP's, RFI's and implementation of Medical Management for new lines of business either at corporate or in the markets.
  • Performs special projects as assigned.
Candidate Education:
  • Required A Bachelor's Degree in Nursing or Health Administration
  • Preferred A Master's Degree in Business Administration, Public Health, Health Administration or related field
Candidate Experience:
  • Required 10 years of experience in Case management, Utilization management, or Quality improvement
  • Required 10 years of experience in Managed care insurance industry
  • Required 5 years of experience in Medicare, Medicaid, and RFI (Request for Information)
  • Required 5 years of management experience
Candidate Skills:
  • Advanced Other Ability to recognize and implement areas for process improvements
  • Advanced Other Advanced ability as a licensed professional to communicate on any level required to meet the demands of the position.
  • Advanced Other Ability to review and interpret contracts
  • Advanced Other Ability to lead a cross functional team with strong people leadership skills
  • Advanced Ability to work within tight timeframes and meet strict deadlines
Licenses and Certifications:
A license in one of the following is required:
  • Required Licensed Registered Nurse (RN)
  • Preferred Other Certification in project management, Quality improvement, or CCM
Technical Skills:
  • Required Intermediate Microsoft Excel
  • Required Intermediate Microsoft Word
  • Required Intermediate Microsoft Outlook
  • Required Intermediate Healthcare Management Systems (Generic)

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Last Updated On: 12/9/2015