This position works with the Medical Directors to lead the respective managers and teams in the ongoing intra- and interdepartmental and external health services operations as related to the Care, Case and Clinical Risk Management (“CM”) process across all Lines of Business (“LOB’s.”)
The Director is responsible for:
This leader marshals the human resources and processes to effectuate ever-improving efficiencies for our customers and provide leadership and direction to our team through the promotion and training of LEAN process improvement and project management.
This work involves significant collaboration with leadership of external and internal stakeholders (e.g. Health Services, Quality, Provider Network, Operations, Customer Care, Provider Partners) and other identified stakeholders for implementation of quality improvement measures and process transformation initiatives. Performance improvement efforts cover a variety of processes, and the Director be sufficiently knowledgeable to recognize important synergies and opportunities in clinical outcomes, cost containment, leveraging resources and provider/member satisfaction.
LEAN process management and Program Management:
Analyze LEAN methodologies, identify, and communicate trends to appropriate departments for review and action.
Work Experience: At least seven years of experience with varied medical exposure required. Minimum of 3 years management or supervisory experience required. Knowledge and experience with Medicaid and Medicare clinical operations in health plans is required. Experience in case management, disease management, utilization management and program development using evidence based medicine required. Experience in Medicare bid process and benefit design is useful. Prior success in healthcare integration, process development and program implementation is desirable. Additional experience managing complex work processes, including, HEDIS, 5 Star and HCC related projects is highly preferred.
Education, Certificates, Licenses: Bachelor degree in health services administration or related field required. Registered nurse with current unrestricted state license is strongly preferred. Maintains current clinical knowledge base and specialty nurse functions. Certified Case Manager (CCM) as accredited by CCMC (The Commission for Case Management Certification), or equivalent.
Knowledge: Knowledge and understanding of disease prevention, medical procedures, care modalities, procedure codes, including ICD-10, CPT Codes, health insurance, and CMMS / State of Oregon mandated benefits. Ability to develop, review, and evaluate utilization reports. Knowledge of and demonstrated experience with quality improvement methodology. Experience giving presentations. Organizational skills with solid experience in using computers and various software applications including Word, Excel, PowerPoint, Outlook, SharePoint, Claims and Care management programs, and audio-visual equipment. Ability to work independently with minimal supervision. Ability to deal with members, patients and families at all levels of care and/or crisis. Thorough knowledge and understanding of PacificSource contractual benefits and appropriate available outside contractual benefits. Thorough knowledge of community services, providers, vendors and facilities available to assist members. Ability to use computerized systems for data recording and retrieval. Ability to supervise and manage a regular staff and a professional nursing staff. Ability to implement goals and objectives of the department within the context of PacificSource’s strategic and management planning. Thorough understanding of PacificSource policies and Health Services Department procedures. Continually seeks to improve quality of service, care, and processes for internal and external customers. Assures patient confidentiality, privacy, and health records security. Accurately interprets contractual benefits. Provides compassionate and confidential service to members/patients. Supports policy and change process, both internal and with providers. Identifies and informs Medical Director of high exposure cases and/or potential reinsurance claims. Keeps the Medical Director apprised of medical management issues. Accountable for service to internal and external customers.
Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 25-35% of the time.
Physical Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.
Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.
PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, national origin, sex, sexual orientation, gender identity or age.