Department: Health Services
Reports to: VP Heath Programs and Services
Plans, develops and directs enterprise Care/Case Management, and Utilization Management functions for Maternal Child Health (MCH). Responsibility for enterprise MCH clinical program development and standardization of the operating model to comply with all regulatory and contractual requirements. Provides leadership necessary to achieve national best practice performance levels and strategic direction for MCH clinical platform capabilities. Develops core curriculum plans, resource models and directs activities for MCH functions enterprise wide. Assesses the effectiveness of these programs in achieving enterprise goals with focus on cost-effective improvement in quality of care for members. Acts as a deployable resource to provide increased support in expanding markets.
Additional Responsibilities:Candidate Education:
- Develops, implements and has oversight of all aspects of the Maternal Child Health (MCH) clinical program. Responsible for overseeing program operations that remain fully compliant with all regulatory and contractual requirements for MCH.
- 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.
- Plans, conducts and directs work on complex projects/programs necessitating the origination and application of new and unique approaches for MCH.
- Establishes budget and monitors for adherence in conjunction with Senior Management. Links budgetary expenses to define improvements in member health and/or cost savings.
- In conjunction with Market teams, 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. Develops systems for close coordination of MCH related functions with departments whose activities directly impact on MCH operations.
- Collaborates with Health Services, Operations, and Information Technology departments to ensure full integration of MCH program operations.
- In conjunction with the Market, establishes professional working relationships with all providers toward the end goal of establishing a care continuum for the MCH and care managed members.
- Leads a continuous improvement of the WellCare MCH Case/Care Management process by developing and disseminating best practices throughout the enterprise.
- Maintain collaboration with Inpatient Services, Outpatient Services, Pharmacy, Customer Services and Quality Improvement to ensure early identification of members in need of MCH Case/Care 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)
- Manages and develops direct reports who include other management or supervisory personnel and/or individual case/care managers who have clinical expertise and are trained in MCH Case Management activities.
- Performs special projects as assigned.
- Required A Bachelor's Degree in a related field Nursing or Health Administration or directly related field
- Required Other or Associate's Degree with RN
- Preferred A Master's Degree in Business Administration, Public Health, Health Administration or related field
- Required 10 years of experience in Directly related Case/Care Management and Utilization Management, preferably in Maternal Child Health
- Required 8 years of experience in healthcare management
- Required 7 years of experience in Managed healthcare working with JCAHO, URAC, AAAHC and the NCQA requirements
Licenses and Certifications:
- 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 Knowledge of healthcare delivery
A license in one of the following is required:
- Required Registered Nurse (RN)
- Preferred Certified Case Manager (CCM)
- Required Intermediate Microsoft Excel
- Required Intermediate Microsoft Word
- Required Intermediate Microsoft Outlook
- Required Intermediate Microsoft PowerPoint
- Required Intermediate Healthcare Management Systems (Generic)