Primary Function

Under the leadership of the Vice President, Health Services is Responsible for the planning, development, implementation and management of the Utilization, Chronic Care and Rapid Response programs. Monitors and implements appropriate interventions to assure achieving cost effective and quality outcomes for membership served within approved Medical Budget. Collaborates with the Sr. Medical Director and Vice President, Health Services to evaluate the effectiveness and clinical outcomes of the Chronic Care Improvement Program.

Responsibilities

• Plans, organizes and directs the development and implementation of Utilization Review, Chronic Care and Rapid Response unit activities. 
• Ensures staff receive appropriate orientation, training and ongoing professional development to meet the needs of the population served. Assists in identifying and establishing educational needs, developing and implementing an education plan, completing educational programs, and monitoring and evaluating the status towards achieving department goals and objectives.
• Assists in the development, implementation, monitoring and ongoing improvement of the Chronic Care department, which includes the functions of rapid response, intensive case management and disease management activities.
• Establishes performance and productivity standards for all associates. Communicates expectations and individual performance quarterly.   Ensures that Chronic Care program enrollment and outreach productivity and performance standards are met. Continuously strives to improve departmental operational efficiencies and workflows.
• Assists the Vice President in preparing the Health Services budget.   Monitors and implements appropriate intervention to achieve operational budge targets.
• Coaches, counsels and implements appropriate disciplinary action within guidelines established by Human Resources.
• Assures congruence and alignment between health management programs and any related medical practice guidelines, utilization management criteria and case management programs. Ensures that medical guidelines are current and valid and communicated to providers and members as appropriate.
• Develops implements and revises policies and procedures required to ensure compliance to NCQA, URAC, and CMS requirements. Audits compliance to standards quarterly and implements appropriate interventions to achieve departmental goals.
• Creates and supports an environment which fosters teamwork, cooperation, respect and diversity. Establishes and maintains positive communication and professional demeanor with health plan employees and clients at all times. Strives to improve associate morale and retention. Demonstrates and supports commitment to corporate goals and mission.
• Completes QI work plan assignments on time and prepares reports of activities to PAC and QIC. Prepares annual program description and program evaluation noting opportunities for improvement. Participates and presents periodic updates as requested to Leadership Team.
• Assists in the annual evaluation of the Consumer Assessment of HealthPlan (CAHPS) member satisfaction survey and Healthcare Employer Data Information Set (HEDIS) results and the Network Provider survey. Identifies opportunities for improvement in process and care and service to members and providers.
• Maintains good rapport with participating network physicians, hospital personnel, social services, ancillary agencies, etc. Acts as health plan liaison with outside entities and regulatory agencies when required.
• Maintains all necessary educational requirements for required licensure and certifications.

Supervisory Responsibilities

Hires, manages and evaluates direct reports and in-direct reports as necessary

Key Competency Success Factors
• Budgetary Responsibility - Develop and maintains department budget. Seeks opportunities to contain cost and increase profitability.
• Corporate Financial Performance – Assists in the establishment and achievement of business objectives for the area of responsibility based upon company’s overall strategic plan and operating goals for this year.
• Performance Management – Develops specific and measurable performance standards for all direct reports.   Holds self and others accountable to goals and standards of department and company.
• Employee Training & Development – Guides and encourages career development, conducts timely performance evaluations and provides open/ongoing constructive feedback to all direct reports.
• Leadership Skills – Leads by example: Sets an example of personal performance, which encourages excellence and integrity. Role models Mission and Values and promotes excellence in customer service through personal actions.
• Job Knowledge – Maintains current knowledge of and applies all applicable licensing, regulatory and industry standards. Keeps abreast of current industry trends.
• Communication Skills – Writes, speaks and presents clearly and concisely. Is thoroughly prepared prior to beginning any negotiation or conflict resolution process.
• Regulatory and Delegation Compliance - Assesses department work quality and develops/implements process improvements to improve and achieve regulatory and oversight compliance.
• Analytical Skills – Analyzes data and makes sound, logical and timely decisions. Establishes priorities and sets long and short term goals

Position Qualifications/Requirements 

Education and Training: RN license required, Bachelor’s or Masters degree preferred
Experience: Minimum of ten years clinical experience with at least five years in managed care and 5 years of progressive management experience
License, Registration or Certifications: Current RN license in the State of Texas or Alabama. CCM certified or eligible for certification within 12 months of hire. Valid drivers’ license.
Computer Skills: Proficient in Microsoft Word, Excel, PowerPoint and Outlook.