The ideal candidate will direct a team of RNs, LPNs, Social Workers, OT/PT specialists and Medical Assistants and will coordinate a wide range of activities in various settings with oversight of care of coordination, case management and utilization management of home health care services, home infusion and DME. T
The director creatively deploys clinical and other resources to flexibly meet the evolving needs of clients as geographic, network and product expansion develop. The Vice President will utilize reliable methods to measure and evaluate the effectiveness of programs in terms of utilization, quality, and medical cost.
Supervises, coaches and evaluate direct reports in the implementation of:
- Utilization Management, applying IQ/Milliman and CMS and local Health Plans’ medical necessity criteria.
- Case Management services including the effective coordination of discharge planning, home care, and specialty pharmacy care.
- Develops and maintains policies, procedures and standards for all channels of case management services in support of internal business goals and external regulatory requirements.
- Clinical acumen, current industry research, trends and benchmarking to develop new approaches to improve utilization and health outcomes for members, creatively and flexibly collaborate with providers, and meet product and market demands.
- Medication Management (reconciliation; substitution; simplification; compliance; management of high-risk medications), in collaboration with the Company’s clinical pharmacists.
- Operations and quality of all pre-acute/post-acute case management programs and transitional care programs, including the assessment of individual patient’s needs; documentation and implementation of the patient comprehensive plan of care including the clinical plan of care designed by the patients’ physicians
- Initiatives in support of advancing standardized metrics such as those promulgated by NCQA/HEDIS, CMS/Star, in support of client demands and Company strategies.
- Multidisciplinary teams that support Transitional Care from higher level of care to Home Care.
- Key success measures for monitoring and evaluating program performance by senior leadership.
- Identification of barriers to success of programs, working closely with other leaders within the Company to develop and implement plans to improve approaches and/or overcome obstacles to improvement.
- Evaluation of outcomes and preparation of failure analyses.
- Appropriate resource allocation for case and utilization management programs in order to maximize quality, efficiency and cost-effectiveness while adhering to corporate budget mandates.
- Communication with physicians both in the provider network and within the Company.
- Communication with Health Plans’ and MSOs’ clients.
- Recruitment and evaluation of performance of professional and nonprofessional staff using effective performance management techniques to promote staff engagement, development, growth and success.
- Effective use of existing systems and tools to manage programs, outreach, and workflows and efficiency.
- Multidisciplinary rounds with nurses and Company physicians to discuss high-risk, high-cost patients.
- Participate to JOC with clients and addresses clients’ concerns, needs and perceived or real performance gaps.
- Internal Quality Assurance Processes.
- Continuous Staff Education.
- Oversight of OASIS reporting.
- Meet Health Plans clients’ delegation requirements, including audits.
- Minimum one (1) year experience as a Registered Nurse in an acute care facility required.
- Atleast Five years (5) of clinical and case management/health coach experience required (Health Plan Experience Preferred)
- Evidence of progressive leadership and management responsibilities
- Experience with developing and maintaining complex relationships in the provider and health care communities
- Must have strong organizational skills, strong interpersonal skills and the ability to handle multiple priorities
- Ability to communicate effectively using written and verbal skills and ability to use of Microsoft Excel and Word (basic use)
- Current unrestricted license in any US State as a registered nurse
- Bachelor and Master of Science in Nursing, of Master of Business Administration preferred
- Certification in case management (CCM), public health and/or community health preferred.
- Certification as Healthcare Coach or obtained within one year of hire.