Job ID: J120651
Company: Gateway Health Plan
Location: Pittsburgh, PA, United States
Full/Part Time: Full time
Job Type: Regular
Posted at: May 25, 2018
Manages and coordinates the supervisory staff that has accountability for the case management, medical review, utilization review, quality management and/or health education team & programs. Monitors and evaluates the operational performance of overall departmental direction, leveraging analytics, regional market trends and utilization trends of members to set future direction and refine current state. Develops longer term plans that will improve utilization, quality and clinical outcomes based on market trends, legislative environment and company’s mission, vision and direction. Responsible for the leadership, performance management for supervisory staff as well as company and department objectives, supporting providers in a variety of health care settings to appropriately identify members with chronic conditions and/or gaps in care that can be positively impacted related to quality and care costs. (note that health care settings could include, but not limited to, working in a physician’s office, visiting physician practices on a routine basis, working within a hospital setting and/or assessing and coordinating member’s care within the member’s home).
1. Performs management responsibilities to include, but are not limited to: involved in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity.
2. Plans, organizes, staffs, directs and controls the day-to-day operations of the department; develops and implements policies and programs as necessary; may have budgetary responsibility and authority.
3. Assists in the development of goal-setting and establishing future direction of the operations of a combined case management/utilization management team and assists with operations planning and efficiency.
4. Ensures overall compliance with applicable business process requirements, regulatory requirements and accreditation standards that support all lines of business.
5. Serves as key resource to both supervisory staff and external sources on complex issues, departmental direction and future planning.
6. Develops proposals to improve overall efficiency and managed care experience, utilization, quality and clinical outcomes. Collaborates with supervisor staff and providers for insights to inform future direction and refinement of overall operations. Collaborates with the appropriate cross- functional leadership and external entities to formulate new, innovative ideas to improve departmental performance, reduce costs while enhancing member experience. Works with internal
7. Other duties as assigned or requested.
Education, Licenses/Certifications, and Experience (For Experience requirements please see appropriate role/level guide. If not applicable, list experience requirements below.)
Knowledge, Skills and Abilities (This section describes additional preferred characteristics)
IV. SCOPE OF RESPONSIBILITY (People Management Responsibility)
Does this role supervise/manage other employees?
V. WORK ENVIRONMENT
Is Travel Required?
Unusual Working Conditions
This position could include meetings in, and travel to provider locations, external agencies, etc. The position is a dynamic one which will require flexibility in work settings and travel.
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