Manages the daily activities of the Field Health Services team comprised of prior authorization, concurrent review, utilization management and case management. 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 and evaluating services and outcomes (clinical and financial) to maximize the healthcare of the member and service to our provider partners.
- Develops, along with the Medical Director, departmental and team member goals and meets with team members on a periodic basis to review and assess associate's performance.
- Oversees the implementation of clinical programs and strategies.
- Accountable for all monthly and quarterly client reports regarding utilization review and case and disease management. Ensures 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 review or case/disease management process.
- Oversees the utilization management-medical advisory committee (UMAC) each quarter along with all agenda, materials and communication with external/internal presenters. Ensures accuracy of meeting minutes and provides to the quality improvement committee timely.
- Partners and collaborates with other departments cross functionally to provide all necessary documents for NCQA and/or state quality reviews 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 develops 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 and collaborates with other departments cross functionally regarding Health Service initiatives and serves as a representative for Health Services on interdepartmental teams.
- Provides guidance on issues related to clinical practice, authorization process, benefits and other utilization and case 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 and case management.
- Performs special projects as needed.
This position is contingent upon the bid award in the state of New Mexico to WellCare Health Plans, Inc.1
- A Bachelor's Degree in nursing, public health, business administration or related field required.
Licenses / Certifications:
- Licensed Registered Nurse (RN) required.
- Certified Case Manager (CCM) preferred
- Certified Professional in Healthcare Quality (CPHQ) preferred.
- 10 years of experience in current case or utilization management. experience with experience in ER/critical care, discharge planning and bedside care required.
- 4 years of management experience required.
- 5 years of experience in managed care required.
- Ability to create, review and interpret treatment plans.
- Demonstrated negotiation skills.
- Ability to lead/manage others.
- Demonstrated problem solving skills.
- Demonstrated interpersonal/verbal communication skills.
- Knowledge of community, state and federal laws and resources.
- Demonstrated written communication skills.
- Ability to effectively present information and respond to questions from families, members, and providers.
- 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 effectively present information and respond to questions from peers and management.
- Ability to work independently, handle multiple assignments, establish priorities, and demonstrate high level time management skills.
- Demonstrated time management and priority setting skills.
- Ability to multi-task.
- Knowledge of healthcare delivery.
- Knowledge of utilization and case management principles and criteria sets such as InterQual, Medicare guidelines, etc.
- Previous experience working with treatment teams to meet the healthcare needs of participants.
- Strong clinical knowledge of broad range of medical practice specialties.
- Intermediate proficiency in Microsoft Outlook, Word and Excel required.
- Intermediate proficiency in Microsoft 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.
- Intermediate proficiency in a Healthcare Management System.