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Field Health Services - Senior Director Job

Full Job Title: Sr Dir, Field Health Services

Job Number: 1805027

St Louis, MO
Phoenix, AZ
Houston, TX

Date Posted: 2018-07-20

Plans, develops and directs the Quality Improvement, Case Management, and Utilization Management functions. Provides leadership necessary to achieve national best practice performance levels in quality improvements, direction and management of the operations for the market Health Services areas, which includes Utilization Management, Field and Telephonic Care Management. Develops core curriculum plans, assigns resources and direct activities for the functions enterprise wide. Assesses the effectiveness of programs in achieving enterprise goals with focus on cost-effective improvement in quality of care for members.

Reports to: State President

Department: Health Services

Position Location: Houston, TX

Essential Functions:

  • Develops and implements the quality improvement plan within regional markets in accordance with the mission and strategic goals of the organization, federal and state laws and regulations, and accreditation standards.
  • Establishes professional relationships with state, stakeholders and community agencies to facilitate quality processes internally and externally for QI, CM, and UM.
  • Analyzes, updates, and modifies standard operating procedures and processes to continually improve QI Department services/operations.
  • 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.
  • Plans, conducts and directs work on complex projects/programs necessitating the origination and application of new and unique approaches for QI, CM, and UM.
  • Establishes budget, obtains approval from senior management and monitor for adherence. Links budgetary expenses to define improvements in member health and/or cost savings.
  • 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 QI, CM, and UM.
  • 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 for special program participation and Quality Improvement. Develops systems for close coordination of QI related functions with departments whose activities are directly a part of the QI Program, including Credentialing.
  • Collaborates with Health Services, Operations, and Information Technology departments to ensure full integration of quality improvement reporting for contract and accreditation compliance.
  • 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.
  • Participates in site visit preparation and execution by regulatory and accreditation agencies (state agencies, URAC,NCQA,CMS,AAAHC,EQRO)
  • Performs special projects as assigned.
Additional Responsibilities:
    Candidate Education:
    • Required A Bachelor's Degree in Nursing or Health Administration or directly related field
    • Required or equivalent work experience 10 years direct leadership experience in Utilization Management, Case Management and/or Quality Improvement in a managed care environment.
    • Preferred A Master's Degree in Business Administration, Public Health, Health Administration or related field
    Candidate Experience:
    • Required 10 years of experience in Directly related Quality Improvement job duties, Case Management, and Utilization Management
    • Required 5 years of experience in Managed healthcare
    • Required 5 years of experience in working with JCAHO, URAC, AAAHC, and the NCQA standards
    Candidate Skills:
    • Intermediate Ability to create, review and interpret treatment plans
    • Intermediate Ability to implement process improvements
    • Intermediate Ability to lead/manage others in a matrixed environment
    • Intermediate Demonstrated interpersonal/verbal communication skills
    • Intermediate Demonstrated leadership skills
    • Advanced Ability to effectively present information and respond to questions from families, members, and providers
    • Advanced Ability to influence internal and external constituents
    • Advanced Ability to communicate and make recommendations to upper management
    • Advanced Ability to influence internal and external constituents
    • Advanced Knowledge of healthcare delivery
    Licenses and Certifications:
    A license in one of the following is required:
    • Required Licensed Registered Nurse (RN)
    • Preferred Certified Case Manager (CCM)
    Technical Skills:
    • Required Intermediate Microsoft Word
    • Required Intermediate Microsoft Outlook
    • Required Intermediate Healthcare Management Systems (Generic)
    • Required Intermediate Microsoft Excel

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      Last Updated On: 12/9/2015