Director of Case and Utilization Management
Under the supervision of the Chief Medical Officer, the Director of Case and Utilization Management is responsible for the assessment, planning, coordination, development, compliance, and evaluation of the Care Management programs. This includes all the functions of Care management including complex case management and transitional case management in both physical and behavioral health. The Director will also liaise with the entities responsible for Utilization Management and create integration workflows. The Director will be accountable for the improved outcomes of members with complex conditions. Under the direction of the Chief Medical Officer, the Director will lead in the design and execution of complex case management and transition of care in accordance with NCQA Case Management Standards and Health Plan client’s requirements. The Director will oversee the ongoing operational excellence and integrity of the care management program including staffing productivity, ongoing training, patient experience, provider integration and overall program impact.
Essential Duties and Responsibilities
- The Director of Case and Utilization management will be responsible for the overall strategy, development, operational performance, and outcomes of the companies’ population health and care management program. The director of care management will provide strategic direction, leadership, and operational oversight to optimize efficiencies and effectiveness of population and care management operations.
- Analyzes clinical, cost, utilization and quality data to identify areas of opportunity to improve performance and identifies/recommends appropriate interventions, including new program development and/or modifications to existing programs.
- Develops and implements case management policies and protocols, ensuring that care management staff is effectively managing cases according to the organization’s high standards and all applicable federal, state, local regulatory requirements as well as terms and conditions included in contracts with managed care partners and any other accreditations that CAIPA attains (e.g., NCQA, DSMES)
- Establishes, monitors and refines, as necessary, staffing models, operating budgets and performance metrics for care management programs.
- Develops competencies, training plan and curricula for various roles performing case management functions.
- The Director of Case and Utilization management should also have a good understanding of population health concepts, which includes telehealth, chronic care management, and remote patient monitoring.
- The role will collaborate with the implementation team and workflow process to develop strategies that will lead to quality, cost-effective and measurable outcomes.
- Participates in development, implements, and annually reviews the Case Management comprehensive Quality Management/Quality Improvement Plan.
- Must be able to gather, develop and track data on evidence-based practice interventions
- Responsible for the timely and accurate reporting to the CAIPA Clinical Committees and Board
- Represents CAIPA at various meetings as required such as regulatory committees, New York State Department of Health, managed care organizational meetings, and external stakeholder organizations as necessary.
- Review and assess provider and facility utilization patterns and provide appropriate education and feedback to outliers and others that would benefit from plan input.
- Drives the implementation of processes and functional enhancements which will improve the overall quality and services provided by the CM teams.
- Collaborates with representatives from other internal CAIPA teams, for example, Quality, Clinical Operations, and Analytics and Outcomes.
- Maintain communication with the department head, with routine updates on operations, issues, concerns, and other pertinent information.
- Maintains current knowledge and insight regarding industry trends related to case management, population health management, value-based care.
- Apprises the Chief Medical Officer of developing and ongoing issues impacting optimal performance within areas of responsibility.
- Perform other duties as assigned by the Chief Medical Officer
- A licensed Registered Nurse in New York or eligible
- At least 3 years of direct patient care experience
- At least 5 years of leadership experience within Care Management in health plans or management service organizations
- Experience in driving change and program development
- Knowledge of reporting standards in utilization management and case management programs under CMS and / or Medicaid Managed Care plans requirements
- Experience in NCQA certification process is a plus
- Ability to work within changing business environment and balance patient advocacy with business needs.
- Experience with managing multiple projects in a fast-paced matrix environment.
- Demonstrated ability to educate colleagues and staff members.
- Successful experience and comfort with change management.
- Demonstration of strong and effective abilities in teamwork, negotiation, conflict management, decision-making, and problem-solving skills.
- Successful ability to assess complex issues, to determine and implement solutions, and resolve problems.
- Success in creating and maintaining cooperative, successful relations with diverse internal and external stakeholders.
- Demonstrated sensitivity to culturally diverse situations, participants, and customers/members.
- Proficiency in Chinese preferred but not required
- Competitive Medical, Vision, Dental Benefits
- Hybrid Work-From-Home and In-Office model
- 401k Retirement Plan
- Tuition Reimbursement