Director of Care Managment

REPORTS TO: Executive Vice President of Customer Delivery
SUPERVISES: All Clinical Operations Staff for Nurse Triage, Case Management and Medical UM

JOB SUMMARY: The Director of Care Management is a full time position, responsible for assisting in the development and implementation of operational, clinical and functional support for the following programs: Nurse Triage, Utilization Management, and Case Management. The Director (1) directs and coordinates all operations to ensure compliance with product development/management, policy and procedures, accreditation, and regulatory standards; (2) provides input into Information Services development/management; (3) offers input and works with the appropriate departments to support the development and launch of new programs; (4) works with clients to deliver quality products and provide excellent customer service; (5) assists product development/management, marketing and sales with the development of product collateral and RFP responses, and assists with presentations for prospective clients; and (6) manages all inbound and outbound call center functions to meet established productivity, performance, and quality standards.

SCOPE OF PRACTICE: Case Management, according to the Case Management Society of America, is defined as; “a collaborative process of assessment, planning, facilitation for options and services to meet an individual's health needs through communicating available resources to promote quality cost-effective outcomes.” This service is recognized as an organized process designed to ensure the medical necessity and cost effectiveness of a proposed service. Case Management is designated to promote optimal recovery and rehabilitation by professional involvement in the rehabilitation process.

MINIMUM QUALIFICATIONS:

Education: Licensed registered nurse with current, unrestricted license required. BS in nursing or Certification in Case Management (CCM) is required. Certification in CM required within 12 months of accepting the position.

Experience: 5 years experience in Triage or Utilization Management or Case Management, and/or other managed care or cost management program, with at least 3 of the 5 years in direct supervision of Case Management required. At least 5 years Call Center Management experience preferred. Experience with application of healthcare criteria systems and programs, e.g. Triage, InterQual, Milliman, or Behavioral criteria. Must have previous experience with URAC and or NCQA accreditation process. Call Center knowledge desirable.

Knowledge/skills:

• Ability to develop and execute product plans, including identification of resources and budget required;
• Excellent communication skills, both verbal and written;
• Ability to direct and coordinate programs, projects, resources, and staff across multiple company functions;
• Strong administrative qualities to analyze goals, products, programs, and processes and make recommendations for changes;
• Knowledge of all aspects of the following managed care products: utilization management, case management, disease management, and triage;
• Organizational and project management skills;
• Experience working with clinical documentation programs designed for case management, disease management, utilization management and triage programs;
• Strong computer skills and experience with Microsoft Office;
• Ability to manage all inbound and outbound call center functions to meet established productivity, performance, and quality standards.
• Strong communication, interpersonal and leadership skills.

ACCOUNTABILITIES:

Job Performance/Responsibilities:

General Duties

• Coordinates and directs all Medical Utilization Management, Case Management, and Nurse Triage programs.
• Assure job descriptions and staff roles/responsibilities are accurate and current;
• Responsible for supervision and oversight of staff;
• Supervise the interviewing and hiring of staff and supervisors for the above programs;
• Assist in the licensing and accreditation process for all programs;
• Assure that all regulatory and accreditation standards are implemented and met;
• Assure that Policies & Procedures, Operational Guidelines, and process workflows are current meet quality accreditation and regulatory standards, and are communicated to and available for staff on the intranet;
• Develop annual Workplan & Evaluation for each program in conjunction with the QI committee (includes goals, objectives, and planned new processes/enhancements) and communicates the Annual Workplan and previous year’s Summary to Senior Management and staff;
• Assist the Quality department in the development and evaluation of an annual QI plan for all programs and assures all indicators are met;
• Participate in the Quality Committee and assists in related functions;
• Analyze all programs to ensure effectiveness, quality, productivity, profitability and patient safety;
• Coordinate all programs and work with other Health Integrated Departments and Committees, i.e. Quality Committee, Education, Account Management, etc;
• Assist in new product development efforts and assures current products are being delivered as designed;
• Assist the Senior Vice-President of Clinical Operations in plans for growth;
• Provide input and direction to Information Services on systems issues and enhancements;
• Offer input and assist with development of orientation, education and training programs;
• Assure delivery expectations of client contracts are being met;
• Assist in the development of management reporting capabilities and works with supervisors to ensure they understand and use them to effectively manage the delivery of services; and
• Provide required reports and special projects as needed.
• Ensure clinical staff consult and seek advise from a licensed physician with expertise appropriate to the types of services being managed.

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