Associate Director of Care Coordination

Overview

Under direction from the Director of Care Coordination, manages and provides direction to the Care Coordination (CC) Department Managers and Supervisors for all product lines.

Responsibilities

• Provides day-to-day direction to CC Managers and Supervisors to meet department goals and objectives.
• Responsible for ensuring performance evaluations are completed appropriately in a timely manner.
• Reviews Performance Evaluations prior to submission to the Director of Care Coordination.
• Participates in the grievance process.
• Coordinates activities with Member Services, Claims, and Provider Relations departments to identify, track, and monitor quality of care issues and trends.
• Responsible for establishing and maintaining reports that will support the efficacy of each CC activity/program and to produce a summary at least annually or upon request that includes a summary of CC program activities,  member outcomes, return on investment, and quality improvement activities.
• Provides oversight and monitoring of the medical claims review, appeals, and grievances within CC to ensure timely accurate response.
• Provides direction and oversight to ensure efficient and appropriate collaboration between the CC staff and the delegated mental health provider and other internal and external organizations.
• Ensures that all policies and procedures are updated at least annually or as needed and presented to appropriate committees for review.
• Works with all other departments to resolve claims, UM, QI, and member issues as necessary.
• Reports any issues with regulatory compliance to Director of Care Coordination and assists in design and implementation of a corrective action plan when necessary.
• Prepares reports on departmental activities according to established schedules and format. Identifies patterns and trends and works with Managers to develop corrective action plans.
• Works with Managers, Supervisors, and Trainer to develop standardized training content and material for new staff and for the ongoing education of existing staff.
• Provides oversight of training program to ensure adequate training accomplishes objectives and results in staff competency.
• Conducts retrospective review for quality, either in the aggregate or on an individual basis, as needed. Provides summaries of findings to the Director of Care Coordination.
• Assists PHC staff and providers with the interpretation of PHC policies, procedures, and regulatory requirements for all product lines.
• Promotes the continuous improvement process and implements recommended changes.
• Participates in all cost containment efforts of both the Health Services department and PHC.
• Develops annual goals for individual performance and updates at least every six (6) months for progress.
• Works with other departments within PHC to develop and implement improvements that will lead to improved performance or enhanced workflow of staff.
• Participates in the planning of new enhanced Health Services products.
• Participates in onsite audits by various regulatory agencies as necessary.

SECONDARY DUTIES AND RESPONSIBILITIES

• Leads, assigns, and participates in special projects and assignments as required.

Qualifications

Education and Experience

Bachelor’s degree in Nursing. Minimum five (5) years of clinical experience; five (5) years of managed care (utilization or case management) experience; minimum three (3) year of management experience in a medical management setting, with effective problem solving in an area where few precedents have been set; or equivalent combination of education and experience.

 

Special Skills, Licenses and Certifications

Current California Registered Nurse license. Effective telephone and computer skills required. Working knowledge and experience with ICDCM and CPT coding schemes. Thorough knowledge of utilization and case management programs and application of related clinical criteria and protocols. Knowledge of and experience with Federal Medicaid and/or California Medi-Cal programs preferred. Ability to work effectively across departments and functions within the organization. Competency with PCs and medical management software, word processing, spreadsheets, etc. Valid California driver’s license and proof of current automobile insurance compliant with PHC policy are required to operate a vehicle and travel for company business.

 

Performance Based Competencies

Demonstrated effective leadership and analytical skills. Effective oral and written communication skills. Excellent interpersonal skills.

 

 

Work Environment And