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
- 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.
- 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
- 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
Licenses and Certifications:
- 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
A license in one of the following is required:
- Required Licensed Registered Nurse (RN)
- Preferred Other Certification in project management, Quality improvement, or CCM
- Required Intermediate Microsoft Excel
- Required Intermediate Microsoft Word
- Required Intermediate Microsoft Outlook
- Required Intermediate Healthcare Management Systems (Generic)