Applies national care management model to local markets. Develops and executes clinical strategies for existing and potential expansion LTC markets. Drives initiatives that result in quality outcomes and cost-effective care for high risk members including LTC. In a matrixed environment, directs leadership, across the enterprise, regarding field CM and LTC best practices. Acts as a deployable resource to provide increased support in expanding markets.
Reports to: VP. Clinical Management
Department: HS Administration
Location: Tampa, FL.- Phoenix, AZ- Brentwood, TN.
- Accountable for the leadership and execution of the clinical components of the field care management to include Long Term Care (LTC) members.
- Drives 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.
- Works with local market Medical Directors and clinical leaders to apply the care and LTC 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.
- Ensures 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.
- Develops 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.
- 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.
- Required A Bachelor's Degree in Nursing (BSN), Health Administration, Business or a related field or equivalent work experience
- Preferred A Master's Degree in a related field
- Required 10 years of experience in A health insurance environment with an emphasis in managed care programs
- Required 5 years of experience in Care Management
- Required 3 years of experience in Long Term Care
Licenses and Certifications:
- Advanced Ability to lead/manage others
- Advanced Ability to work as part of a team
- Advanced Demonstrated interpersonal/verbal communication skills
- Advanced Ability to work in a matrixed environment
- Advanced Other Analytical with the ability to drive change
- Advanced Other Must be able to effectively maintain/build relationships across business and/or functional areas
- Advanced Other Demonstrated contributor in a health care or managed care environment.
A license in one of the following is required:
- Required Licensed Registered Nurse (RN)
- Required Intermediate Microsoft Excel
- Required Intermediate Microsoft Word
- Required Intermediate Microsoft Outlook
- Required Intermediate Microsoft PowerPoint