Our client is a Fortune 50 company that has an integrated healthcare model that is proving to be successful in the market. We are seeking a Director of Medical management who will report into the CMO of the organization. Primary duties may include, but are not limited to oversee care management operations across a wide range of products, clients and states including meetings with key major account clients. This is not a remote position.
This is an awesome opportunity to lead strategy and operations for the centralized National Utilization Management function in the organization. The ideal candidate will oversee a team of 45 and will work closely with the Sr. Medical Director on all UM functions. The immediate challenge will be to modernize processes and create the best in class UM function.
- Leads and participates in cross functional corporate teams which design and implement new care management programs that may impact multiple lines of business.
- Develops and implements process and program redesigns.
- Leads multiple teams of clinicians charged with promoting quality member outcomes, to optimize member benefits, and to promote effective use of resources.
- May direct multiple medical management programs including utilization management, case management, demand management and disease management programs, which typically support multiple lines of business.
- May also manage appeals for services denied. Staff size is typically large, located in multiple sites and/or states and utilizes multiple systems.
- Ensures adherence to all contract, regulatory and accreditation requirements. Develops short/long-term objectives and monitors processes and procedures to ensure consistency with the enterprise and compliance with state and federal regulations.
- Collaborates with matrix Care Management partners (such as IM or PE&C) to resolve issues or find solutions. Manages budget and special projects. Hires, trains, coaches, counsels, and evaluates performance of direct reports.
Requires a BS in nursing or related health care field
A minimum of 8 years of experience in a health care environment (i.e. acute care) including management experience; or any combination of education and experience, which would provide an equivalent background.
MS or advanced degree in a clinical nursing specialty, business or healthcare-related field preferred.
Current active unrestricted RN license to practice as a health professional within the scope of practice in applicable state(s) or territory of the United States required.
Must have significant experience in care delivery, case management and/or population health.
Accomplishments should include identifying UM opportunities to drive cost of care down
Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.