This person is responsible for managing the utilization and care management processes for a member population of varying medical complexity and ensuring the delivery of essential services that address the total healthcare needs of members. Primary duties may include, but are not limited to:
Ensures program compliance and identifies opportunities to improve the customer service and quality outcomes.
Oversees the development and execution of medical and case management policies, procedures, and guidelines; assists in developing clinical management guidelines.
Ensures medical management activities are contracted, reviewed and reported.
Supports quality initiatives and activities including clinical indicators reporting, focus studies, and HEDIS reporting.
Hires, trains, coaches, counsels, and evaluates performance of direct reports.
Qualifications
Requires a BA/BS in a health care field; 8 years of clinical experience, including prior management experience; or any combination of education and experience, which would provide an equivalent background.
RN, LCSW, or LPC preferred.
National Committee for Quality Assurance (NCQA) accreditation and HEDIS reporting experience preferred.
Masters in a health care field or MBA with Health Care concentration preferred.
Certified Case Manager preferred.
Pass it on for Referral Bonus. Not the right role for you, but know someone we should meet? Share with him to earn $1,000 referral bonus.
Posts
