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For those who want to invent the future of health care, here's your opportunity. We're going beyond basic care to health programs integrated across the entire continuum of care. Join us and help people live healthier lives while doing your life's best work.(sm)The Director of Care Management is responsible for planning, organizing, and directing the assigned regional operations for Care Management services. The Director coordinates duties with appropriate personnel to meet operational program needs, ensures compliance with state and federal health plan requirements, Medicare guidelines and URAC/NCQA standards; develops and implements policy and procedures; updates and integrates current clinical practice guidelines; performs employee counseling, performance appraisals, and oversights employee training and development. The success of this position requires the ability to foster communication and teamwork between physicians, market care management team, utilization management staff, corporate departments, vendors, and senior leadership. This position is responsible for oversight and evaluation of all Care Management programs. The Director will assist senior leadership with long-term planning initiatives to maintain operations assuring activities are appropriately integrated into strategic direction, as well as the mission and values of the company.Primary Responsibilities:
Participates, provides input, and impacts outcomes of the following:
Medical Management Committee
Market Success Meetings/ Best Year Yet
Care Coordination Steering Committee
Market Patient Care Coordination Meetings
Tier I Provider Market Meetings
Responsible for planning and implementing assigned market and regional market success initiatives with each market care management and operations team to include:
Overall Health Care Cost PMPM
Quality of Care Metrics
Acute patient care episodes through Admits/k, Readmits %, ER visits/k
Directs, plans, and supervises activities for assigned team/region in an efficient and effective manner utilizing time management skills to facilitate the total work process
Provides constructive information to minimize problems and increase customer satisfaction
Spends time in each assigned market mentoring team members, fostering relationship with market operations team, and providing resources for vendor and provider education needs
Provides effective problem solving, works as a care management liaison and resource with all customers internal and external to provide optimal customer satisfaction
Maintains current knowledge of health plan benefits and provider network including inclusions and exclusions in contract terms
Guides physicians in their awareness of preferred contracts and providers and facilities
Participates in the development, planning, and execution of continual process improvement efforts, policies and procedures, and regulatory compliance functions related to care management activities
Coordinates all activities related to delegated and regulatory requirements
Develops initiatives for process improvement of care management programs
Develops new policies, procedures, job aids, and work flows that enhance operating efficiency of the care management programs or activities
Evaluates the success of process improvement efforts and implements solutions for growth opportunities
Evaluates care management staff performance by providing monthly management level and role level report cards
Provides coaching for performance success, recommends merit increases, and consistently executes disciplinary actions/PIPs
Interviews, hires, and retains quality licensed staff to meet business needs
Ensures the timely preparation of reports and records for dissemination to stakeholders to include:
Monthly Market Metrics
Market Pilot Outcomes
Market Success Initiative Key Outcomes and Milestones
Monthly Team Member Report Cards
Completes and manages regional budget effectively
Conducts and/or participates in departmental meetings, patient care coordination meetings, and interdisciplinary team meetings as required for care management activities
Conducts annual evaluation of regional care management program
Performs all other related duties as assigned
This position will be based out of the Dallas or Fort Worth Office.Required Qualifications:
Bachelor of Science degree, in Nursing, Management, Business Administration or related field required (or eight years of experience in the managed care, disease management, or utilization management field)
Registered Nurse with current license in Texas, or other participating states
Case Management Certification (CCM) or ability to obtain within eighteen months of hire
8+ years of experience in managed care and/or disease/utilization management with a minimum of three years at the management level or above
Knowledge of federal and state laws and URAC/NCQA regulations relating to managed care, disease management, utilization management, transition planning and complex care case management
Knowledge of basic principles and practices of clinical nursing
Knowledge of referral processes, claims, case management, and contracting and physician practices
Knowledge of fiscal management and human resource management techniques
Proficient with computer software programs, to include: word processing, spreadsheets graphics and databases
Ability to travel in and/or out-of-town
Preferred Qualifications:
Master’s degree
10+ years of experience in managed care and/or disease management with a minimum of five years at a management level
3+ years of experience working in a call center environment.
Prior multi-site regional operations management responsibility
Effective written and verbal communication skills
Ability to effectively plan programs and evaluate accomplishments
Ability to present facts/recommendations in oral and written form
Ability to analyze facts and exercise sound judgment arriving at proper conclusions
Ability to plan, supervise and review the work of professional and support staff
Ability to apply policies and principles to solve everyday problems and deal with a variety of situations
Ability to exercise initiative, problem-solving, decision-making
Ability to establish and maintain effective working relationships with employees, managers, healthcare professionals, physicians and other members of senior administration and the general public
Careers with WellMed. Our focus is simple. We're innovators in preventative health care, striving to change the face of health care for seniors. We're impacting 240,000+ lives, primarily Medicare eligible seniors in Texas and Florida, through primary and multi-specialty clinics, and contracted medical management services. We've joined Optum, part of the UnitedHealth Group family of companies, and our mission is to help the sick become well and to help patients understand and control their health in a lifelong effort at wellness. Our providers and staff are selected for their dedication and focus on preventative, proactive care. For you, that means one incredible team and a singular opportunity to do your life's best work.(sm)Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.Job Keywords: CCM, case management, director, compliance, regulatory, dallas, fort worth , tx , texas , CMS , medicare , managed care, manager
