Applies national care management model to local markets. Executes clinical strategies for existing and potential expansion LTC and LTSS markets. Drives initiatives that result in quality outcomes and cost-effective care for high risk members including LTC and LTSS. In a matrixed environment, directs leadership, across the enterprise, regarding field CM and LTC/LTSS best practices. Acts as a deployable resource to provide increased support in expanding markets.
Department: HS-Case Management
Reports to: Sr Dir, Model of Care
Location: Tampa, FL (Henderson Rd)
- Accountable for the execution of the clinical components of the field care management to include Long Term Care (LTC) and Long Term Support Services (LTSS) members.
- Supports the development and implementation of long-range plans, goals, and objectives. Directs and coordinates a broad range of activities and functions to ensure effective operations and the achievement of organizational objectives.
- Participates in the development of the field care model for high risk members including LTC and LTSS.
- Works with local market Medical Directors and clinical leaders to apply the care and LTC & LTSS models to their populations to include high risk Aged Blind and Disabled, Medicare, and LTC, and TANF members. Refines the care model play book based on local input.
- Oversees the successful implementation of the model of care and best practices including training, auditing, setting staffing ratios, contributing to talent selection when needed and implementing new markets. Partners with field clinical teams to remediate poor performance.
- Supports the processes and procedures to ensure department-wide compliance with contractual, regulatory and accreditation agencies.
- Optimizes processes and work flows to achieve successful outcomes and benefit maximization within the scope of responsibility.
- Takes appropriate actions to increase revenue, leverage resources, minimize expenses. Participates in the bid/procurement process to ensure company goals are deployed across the portfolio of businesses and bids.
- Participates in the strategic planning and annual forecasting activities for LTC. Has accountability for assessing market dynamics, competitive position and operational performance for the clinical LTC team.
- Lead SME for RFP documentation for LTC and LTSS working with clinical program development director.
- Builds and enhances relationships with community based partners to support WellCare's mission and create compliant opportunities for growth.
- Establishes department policies and procedures and develops training to support associate and leader development. Develops, monitors and analyzes metrics related to staff productivity.
- Takes the appropriate actions to ensure compliance within all areas of the business for which there is accountability.
- Performs other duties as assigned.
- A Bachelor's Degree in Nursing (BSN), Health Administration, Business or a related field or equivalent work experience is required
- A Master's Degree in a related field is preferred
- 7 years of experience in A health insurance environment with an emphasis in managed care programs is required
- 5 years of experience in Care Management is required
- 3 years of experience in Long Term Care is required
- 3 years of experience in Management is required
- Advanced ability to lead/manage others
- Advanced ability to work as part of a team
- Demonstrated interpersonal/verbal communication skills
- Advanced ability to work in a matrixed environment
- Advanced analytical skills with the ability to drive change
- Must be able to effectively maintain/build relationships across business and/or functional areas
- Demonstrated contributor in a health care or managed care environment.
A license in one of the following is required:
- Licensed Registered Nurse (RN) or licensed behavioralhealth professional (i.e. LCSW, LMHC, LPCC) is required
- Required intermediate Microsoft Excel, Word, Outlook and PowerPoint