Director of Clinical Services - Case Management

Pay Rate: $100,000 - $150,000 per year

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Position Summary:
The Director, Case Management Ensures compliance with specific DMHC DHCS CMS NCQA, an health plan requirements by the network and its affiliated Medical Groups in the areas of Case Management Care Coordination and Transition of Care(collectively referred to as CM or Case Management). The Director oversees, creates, maintains and implements our CM Program, Work Plans, Policies and Procedures as well as comprehensive compliance activities and interventions for Case Management functions. Works collaboratively with the our Sr. Directors and Vice Presidentsto assure Case Management requirements are fully integrated into P NH medical group delegation oversight and monitoring, health plan compliance/oversight, quality and analytic functions. Assures proactive internal quality monitoring and a state of constant readiness of our network & affiliated groups to meet regulatory and accrediting requirement. The Director is accountable to act as a liaison and advisor to the CM business owners within affiliated medical groups to enable groups to develop and maintain compliant processes, record keeping a reporting The Director is also responsible for maintaining relationships with all contracted hea plans' delegation oversight and/or CM points of contact. Work is complex and requires a high degree of independent judgment, emotional intelligence and personal initiative.

Essential Duties and Responsibilities include the following:

1. Leading the health plan Case Management function,the Director works collaboratively with
Medical Group CMI headers and our network UM leaders to ensure:
a. Accurate case management health plan reporting
b Accurate reporting of CM data by Groups to our network analytic
c. Successful CM health plan audits by the network and Group
d. Clear understanding of delegated CM responsibility
2. Provides guidance and expertise to Medical Group CM leaders including but not limited:
a. Response to and closure of Corrective Action Plan
b Regulatory and accreditation requirement
c. Health plan delegated responsibility
d. Achievement of Regulatory, Health Plan and our company performance standards
e. Operational effectiveness and efficiency.
3. In conjunction with leadership, implements strategies and processes to ensure ongoing readiness and compliance withDMHC and NCQA CM requirements. Leads efforts for our network to achieve and maintain NCQA CM accreditation
4. Provides expertise and input in the development review and updating of our Policies and Procedures for CM functions.
5. Assures CM requirements are met in ongoing activities including but not limited
a. CM policies and procedures
b Development updating of Program descriptions, Provider Manual, Work plans,
Program evaluations, delegation oversight tools and required documents
c. Develops and updates key training programs for Affiliated Medical Group use
d. Preparing, submitted and presenting required materials and information tothe UMC/QIC committee.
6. Develops & maintains collaborative and positive working relationships with all health plans' contacts and affiliated medical group key contact
7. Establishes a positive, collaborative and productive work environment with our Clinical Services (UM and Q departments).
8. Promotes a positive collaborative relationship with other departments.
9. Work collaboratively with Director of Analytics to develop reports and monitors to Group performance
10. Assures compliance with HIPAA requirements.
11. Involved in and directs projects that are viewed as being critical to the organization a whole
12. Serves as a member of the management team, offers operational guidance and plays essential role in the success of the organization
13. Provides project management expertise, oversight, and guidance to projects of high importance
14. Manages and ensures appropriate and timely follow up on internal and external request information or action
15. Other duties as assigned

B. Education, Skills and/or Experience:
1. Graduate from an accredited school for Nursing
2. Unrestricted Active California Registered Nursing License
3. CCM Certification required.
4. Minimum five years leadership experience at the Director level or above; minimum three years in Case Management.
5. Minimum five years minimum of Case Management experience at aHealth plan or delegated group/IPA.
6. Five to Seven (5-7) years of clinical experience preferred
7. Demonstrated knowledge of regulatory requirements including DMHC, DHCS, CMS and NCQA requirements.
8. Proficient in MS Office programs (i.e., Word, Excel, Outlook, Access, and PowerPoint).
9. Typing 60 words per minute with accuracy.
10. Ability to deal with responsibility with confidential matters.
11. Able to manage and prioritize multiple projects simultaneous
12. Must have strong analytical, creative problem solving, and organizational sk
13. Ability to strategize effectively, execute within timelines, and deliver quality results
14. Must have the ability to work with all levels of management and have the ability to develop positive working relationships across the company.

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