Director, Medicare Care Management

Who we are

Community Health Plan of Washington is an equal opportunity employer committed to a diverse and inclusive workforce. All qualified applicants will receive consideration for employment without regard to any actual or perceived protected characteristic or other unlawful consideration.

Our commitment is to:

• Strive to apply an equity lens to all our work. 
• Reduce health disparities. 
• Become an anti-racist organization. 
• Create an equitable work environment. 

About the Role

Responsible for the direction and coordination of care management activities to manage the care of the member over the continuum of care, including both physical and behavioral health services, for Medicare Advantage and Dual Special Needs Plan members. This role encompasses the effective and efficient management of human, fiscal and other resources, development of staff competency through assessment and education, compliance with regulatory and professional standards and strategic planning, improvement of quality, service levels, safety, customer satisfaction and of collaborative relationships within CHPW and CHNW.

To be successful in this role, you:

• Bachelor’s degree in Nursing or a master’s degree in social work and/or a relevant health field required
• Master’s degree in Nursing, Healthcare Administration, Public Health, or Business strongly preferred
• Current, unrestricted license in the State of Washington as an RN required, if applicable
• Current, unrestricted license in the State of Washington as a Social Worker (LSWAA, LSWAIC) required, if applicable
• Certification as a Case Manager required
• As this position involves traveling on behalf of the Company, a current driver’s license and an acceptable driving record is required
• A minimum of seven (7) years progressively responsible management experience in the areas of case management, population health and/or disease management required, including a minimum of five (5) years progressive experience working with medical and behavioral case management required

Essential Functions and Roles and Responsibilities 

• Designs and implements systematic and comprehensive care management policies and procedures that ensure high quality care management application to positively impact member outcomes.
• Administers and ensures care management programs meet compliance and regulatory standards as required by Centers for Medicare & Medicaid Services (CMS), DSNP Model of Care (MOC), Washington Health Care Authority (HCA), and/or National Committee on Quality Assurance (NCQA) for continued accreditation of the health plan, as well as state and federal regulations, quality metrics and evolving models of care.
• Provides oversight of programs within assigned lines of business including development, implementation of program components, quality data collection and monitoring, auditing of program requirements and reporting outcomes to appropriate leadership and committees.
• Responsible for a strong understanding of health plan benefits for all lines of business.
• Defines strategy to identify and assess outlying and high-risk cases to determine plan of care.
• Develops and designs procedures, processes, productivity targets, quality of care and financial goals, and new delivery models for medical and behavioral health care management.
• Collaborates with Medical Directors, Healthcare Analytics, Network Management and other departments as needed to collect, analyze, and report on effectiveness of programs and address quality of care issues. Uses data to guide the development and implementation of health care interventions that improve value to the member.
• Collaborates with internal leaders to deploy a coordinated regional approach to member and provider services in each region across the state.
• Drives strategy for the development, reporting, monitoring, and analysis of department measures that are linked to organizational goals especially as pertains to achieving enrollment targets in care management programs and return on investment projections on care management programs.
• Works collaboratively with other members of the Clinical Services Leadership Team to establish mechanisms and processes to regularly analyze the different Plan populations for variances in clinical and service quality to identify and recommend the highest impact opportunities and department-level strategies for interventions.
• Delegates responsibilities to managers and provides professional development opportunities for team leaders.
• Provides leadership in developing, implementing, and communicating short and long-