This job is responsible for the provision of leadership, direction, oversight, and operations management for the Organization's Medical Management functions across all lines of business including commercial and government programs. This position interprets key performance metrics to develop plans, mobilize the work force, and achieve the Organization's medical management outcomes relative to the Triple Aim (improved population health, improved experience of care, and lower healthcare costs). The incumbent builds and maintains strong collaborative partnerships with key partners in the Clinical Services organization including Utilization Management, Performance Improvement, Medical Management and Policy including Quality and Medical Review and Appeals, Pharmacy, and Provider Integration to identify, develop, implement, and monitor performance metrics related to Care Management and Clinical Operations. This position also builds strong collaborative partnerships internally and externally with key stakeholders and vendors to ensure that internal and external Care Management programs are well-coordinated and work cooperatively to achieve outcomes goals. This position will also work closely with providers such as AHN, strategic partners, etc. to maximize outcomes. Areas of direct responsibility include Government Complex Case Management, Commercial Complex Case Management, Disease Management, and Strategic Health Promotion.
- Perform 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.
- Plan, organize, staff, direct and control the day-to-day operations of the department; develops and implements policies and programs as necessary; may have budgetary responsibility and authority.
- Participate in strategic planning and in the establishment of strategic directions and goals for all clinical services operations.
- Participate in the establishment, monitoring, and reporting of key metrics to manage performance related to clinical services processes and functions .
- Accountable for achieving established outcomes goals relative to clinical services operations.
- Build alliances across the business and clinical leadership teams with the end objective of a collaborative, efficient and viable operating model.
- Innovate and implement new or revised models for the Organization's clinical operations functions in response to evolving trends in healthcare delivery and/or emerging models of care.
- Serve as a change agent, assisting others in understanding the importance, necessity, impact and process of change through active involvement in decision making and coaching of leaders and staff.
- Utilize proven performance improvement methodologies and incorporates a strong emphasis on data to drive the implementation of improvements in the Organization's clinical operations and organizational culture in order to achieve improved outcomes metrics relative to the Triple Aim(improved population health, improved experience of care, and lower healthcare costs).
- Accountable for maintaining updated, current competencies, knowledge and skills in healthcare management trends, legal/regulatory and accreditation standards, and payer-based best practices in medical management and for the application of such current concepts within the Organization’s clinical operations strategies, processes and functions.
- Accountable for leadership and oversight of front line operational organization including case managers, care managers and non-clinical customer service reps.
- Other duties as assigned or requested.
- Bachelor's Degree. Health/Clinical degree preferred (BSN, PA), or business related (Business, Health Administration)
- Master’s degree in Business, Healthcare Policy, Health Administration, Economics, or related field or equivalency demonstrated through a combination of years of experience and proven skills. Also require bachelor's degree in Nursing.
- 10-12 years of experience in clinical services and/or health plan care management functions with at least 5 years of experience in a senior leadership position
- Significant experience in case management, disease management, utilization management, and population health with solid knowledge of best practices in all aspects of medical management
- Proven ability to use medical management metrics and to develop data-based initiatives designed to improve outcomes relative to the Triple Aim
- Demonstrated ability to lead and motivate clinical and administrative groups to achieve specific objectives
- 10-12 years of experience in clinical services and/or health plan care management functions with at least 5 years of experience at the executive or director level
- Clinical leadership experience in multiple settings of care (e.e. ambulatory, acute and post-acute care)
- Clinical leadership experience in both the provider setting and in health plan or payer settings
- Exceptional verbal, written and interpersonal communication skills
- Solid understanding of the healthcare delivery systems and healthcare finance
- Solid understanding of applicable regulatory and accreditation standards and requirements
- Proficiency in computer usage, including database and spreadsheet analysis
- Highly developed organizational and leadership skills
Language Requirement, other than English
0% - 25%
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies
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