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Director of Medical Management

The Director of Medical Management is responsible for planning, organizing, budgeting, and directing the assigned regional operations for Medical Management services. The Director is in a dynamic position to impact the transition of care of the member across the care continuum, work with all levels of providers and stakeholders, support the financial well-being of the organization and most importantly, drive quality and value-based member outcomes. The Director applies leadership and management skills to building strong and productive relationships across the broad spectrum of external organizations that include health systems, provider, vendor and regulatory agencies. The Director coordinates duties with appropriate personnel to meet operational program needs, ensures compliance with state and federal health plan requirements, Medicare guidelines and URAC/NCQA standards; develops and implements policy and procedures; updates and integrates current clinical practice guidelines; performs employee counseling, performance appraisals, and oversights employee training, coaching and development. The success of this position requires the ability to foster communication and teamwork between physicians, market care management team, case, utilization, disease and transition of care management staff, corporate departments, vendors, and senior leadership. This position is responsible for strategic planning, oversight and evaluation of all Medical Management programs. The Director will assist senior leadership with long-term planning initiatives to maintain operations assuring activities are appropriately integrated into overall Health Alliance strategic direction, as well as the mission and values of the company.

Qualifications: EDUCATIONAL REQUIREMENTS
Bachelors Nursing

CERTIFICATION & LICENSURE REQUIREMENTS
RN License Illinois. Case Management Certification obtained within 18 months of hire.

EXPERIENCE REQUIREMENTS
Five (5) to seven (7) years of progressive nursing experience in an integrated healthcare setting with a minimum of three (3) years at a recent management level of manager or above required. Three (3) or more years of experience working in a health plan environment required.



Essential Functions: •Directs overall functions of the Medical Management Department and promotes values of teamwork, accountability, empowerment to enforce and maintain positive interdepartmental working relationships for the purpose of streamlining operations and enhancing employee satisfaction.
•Directs the identification, implementation, and monitoring of a focused medical management program, annual plan, and annual evaluation for Health Alliance at the corporate level.
•Oversees all medical management activities for improvement in care and service and alignment with regulatory standards including but not limited to NCQA, CMS, IFMC, Rural Health Boards, IDPH; develops action plans around identified gaps; and prepares documentation for submission to regulatory agencies to meet requirements.
•Analyzes data to monitor trending of quality and utilization practice patterns to identify improvement opportunities that reduce medical spend.
•Identifies patterns of care and opportunities that improves the utilization of resources.
•Monitors work flows and implements improvements.
•Identifies training needs and develops training materials.
•Drives improvements in quality whiles slowing the growth in health care spending.
•Demonstrates program outcomes and communicates results with appropriate stakeholders on a regular basis.
•Responsible for the transition of care process across multiple levels.
•Manages outsourced services related to medical management.
•Evaluate and report quality and medical management activities routinely at the Health Alliance Quality Improvement Committee, Medical Director Committee, Joint Venture Partners, and Quality Committee (subcommittee of the Health Alliance Board).

Time:  Full time
Salary:  Salary
Category:  Operations

Updated: 3/26/2018 11:02:02 AM