PacificSource Health Plans

Director, Case Management

US-OR-Bend
Job ID
2017-379E
Type
Regular Full-Time
Hiring Pay Range
$101,000-$140,000
# of Openings
1
Status
Exempt

Overview

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:

  • All Care Management programs, plans and policies in accordance with strategic business objectives, professional standards and applicable regulatory requirements for all LOB.
  • Facilitates, guides, creates, and monitors data and relevant analytics for ongoing operations and regulatory oversight bodies;
  • Participates and prepares appropriate materials for relevant committees and oversight bodies;
  • Facilitates and oversees audit processes and assists in identification and resolution of gaps.
  • Able to interpret/explain complex information and outcome measures to key stakeholders

 

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.

Responsibilities

 

 

 Essential Responsibilities:

 

  1. Manage and improve the performance of the Case Management processes and microsystems through effective oversight and coaching of teams, managing team performance, monitoring daily workflow, and improving processes and outcomes.
  2. Responsible for improvement of engagement scores across LOB’s. Responsible for hiring, staff development, coaching, performance reviews, corrective actions, and termination of employees. Provide feedback, including regular one-on-ones and performance evaluations, for direct reports.
  3. Oversee and assist in providing exceptional service and information to members, providers, employers, agents, and other external and internal customers.
  4. Monitor, evaluate, and report performance for the teams relating to volumes, timelines, accuracy, customer service, and other performance objectives, including regulatory compliance.
  5. Participate in relevant compliance activities and audits and reporting.
  6. Support related PacificSource departments, facilitate audit processes and assist in the identification and resolution of gaps.
  7. Ensure internal departmental awareness and inclusion of CMMS and Oregon Health Authority rule and guideline updates and those of other relevant regulatory bodies.
  8. Review case management programs for trends, opportunities for improvement and cost containment strategies.
  9. Maintain excellent working knowledge of Medicare and Medicaid Governmental rules and regulations as well as those applicable to the Commercial LOB, to ensure that project operations remain compliant. Present and document pertinent information to support project recommended action plans.
  10. Standardize systems, processes, and policies across the company, where feasible.
  11. Ensure that medical benefits are administered consistently to meet contract obligations and to ensure regulatory compliance.
  12. Continually seeks to improve quality of service, care, and processes for internal and external customers.
  13. Provide oversight and expertise to case management in efforts to integrate physical health and behavioral health programs.
  14. Investigate and settle issues as needed. Handle dispute resolution or relay information to appropriate departments and personnel for further resolution.
  15. Serve as liaison with all PacificSource departments to coordinate optimal provision of service and information. Participate in management planning, Request for Proposals (Medicare/Medicaid applicable oversight), complete annual reports as required by states we serve.
  16. Maintains oversight of applicable quality regulations and certifications.
  17. Work in concert with product developments and compliance in the development of handbooks, contracts and benefit summaries.
  18. Serve on various interdepartmental and company committees as required or designated and report any pertinent communications back to the teams or departments.
  19. Provide for operational excellence through management reports, up-to-date systems, and strategic initiatives
  20. Monitor caseloads and workflow of nurses, department representatives, functional specialists, and team managers or coordinators to assure appropriate distribution and processing of tasks
  21. Develop and support improvement of skills, performance, professional acumen, and educational needs of clinical and operational teams.
  22. Remain current in specialty field and keep apprised of current and anticipated trends in medical management.
  23. Develop policies, procedures, guidelines, and other operational protocols for the Health Services Department. Informs the development, monitoring and implementation of pertinent policies and procedures for Health Services within CMS, PPACA, NCQA, HIPAA and State/Federal requirements.
  24. Evaluate and recommend systems additions and upgrades as appropriate.
  25. Actively pursue partnerships and build relationships with key healthcare stakeholders in the communities served by PacificSource.
  26. Responsible for oversight, management, development, implementation, and communication of department programs.
  27. Develop annual department budgets. Monitor spending versus the planned budgeted throughout the year and take corrective action where needed.
  28. Coordinate business activities by maintaining collaborative partnerships with key departments.
  29. Responsible for process improvement and working with other departments to improve interdepartmental processes. Utilize lean methodologies for continuous improvement by using visual boards and daily huddles to monitor key performance indicators and identify improvement opportunities.
  30. Actively participate as a key team member in Manager/Supervisor meetings.
  31. Actively participate in various strategic and internal committees in order to disseminate information within the organization and represent company philosophy.
  32. Work with IT and Analytics on prioritization of software changes and needed Informatics upgrades. Liaison between Medical Directors and IT / Informatics / Analytics to support appropriate reporting packages for internal and external use
  33. Act as primary liaison with Commercial and Government operations.
  34. Work collaboratively with the UM Director to ensure seamless care transitions across the care continuum and to establish best practice strategies for managing members across LOB’s.
  35. Manage Health Services contracts, their data, and required reporting to meet regulatory and business needs.
  36. With Medical Directors, act as liaison and resource for Provider-Payer partnerships.

 

 LEAN process management and Program Management:

 

Analyze LEAN methodologies, identify, and communicate trends to appropriate departments for review and action.

  1. Assist stakeholders, community partners, and internal departments in implementation of LEAN processes and procedures.
  2. Standardize systems, processes, and policies across the company, where feasible.
  3. Identification of costs and benefits of programs inter- and intra-departmentally
  4. Work / coordinate with relevant parties to review of post – care costs audits for accuracy of billing and coding.
  5. Work / coordinate with Marketing and Communications with preparation and review of member – facing communications.

 

Supporting Responsibilities:

 

  1. Serve on designated committees, teams, and task groups, as directed.
  2. Work with Medical Directors in responding to inquiries or complaints and pertinent report preparation for other review functions.
  3. Represent the Heath Services Department, both internally and externally, as requested by the Medical Directors.
  4. Participate in and support project teams led by other departments and provide necessary input to support the goals of colleagues.
  5. Meet department and company performance and attendance expectations.
  6. Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
  7. Perform other duties as assigned.

 



 

 

 

 

 

Qualifications

SUCCESS PROFILE

 

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.

 

 

Competencies

Our Values

  • Authenticity
  • Building Organizational Talent
  • Coaching and Developing Others
  • Compelling Communication
  • Customer Focus
  • Empowerment/Delegation
  • Emotional Intelligence
  • Leading Change
  • Managing Conflict
  • Operational Decision Making
  • Passion for Results

 

 

  • We are committed to doing the right thing.
  • We are one team working toward a common goal.
  • We are each responsible for our customers’ experience.
  • We practice open communication at all levels of the company to foster individual, team and company growth.
  • We actively participate in efforts to improve our many communities-internal and external.
  • We encourage creativity, innovation, continuous improvement, and the pursuit of excellence.

 

 

 

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.

 

 

 

 

 

 

 

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