Director, Care Management (RN or LCSW)

Job Summary

The Director, Care Management  will mainly be responsible for the operational component of the Care Management (CM) Department with the main goal of improving key L.A. Care members healthy and access appropriate services. The Director will also work with the CM Medical Directors and key staff in designing, enhancing and implementing programs, plan strategically and report on regulatory requirements.   

One of the key initiatives is to increase our community CM presence. The Director is also responsible for providing evidence of ongoing compliance with all regulatory and accreditation requirements (i.e. health risk assessments and interdisciplinary care plan and care team programs, population health management. The Director is also responsible for outreaching and working with key stakeholders and provide subject matter expertise in support of the oversight, outreach and training of our Plan Partner Health Plans and Delegated Provider Groups.

This position will direct all aspects of running an efficient  team, including hiring, supervising, coaching, training, disciplining, and motivating direct-reports.

Duties

General Essential functions: 
Collaborating with the Medical Director, responsible for the operations, programming and oversight of internal L.A. Care’s Care Management Department, collaborates with internal and external delegates and any operations associated with the Care Management department.  Functions currently include all care management programs (Complex Care Management, Care Coordination and Disease Management).  

Ensures the CM department performs the following:  

All contracts [(i.e. Centers for Medicare and Medicaid Service (CMS), California Department of Health Care Services (DHCS)], California Department of Managed Health Care (DMHC) regulations, applicable state and federal regulations, National Committee on Quality Assurance (NCQA) CM Certification, Management Services Agreements & Other Contracts.  

Oversees and monitors operational compliance with organizational standards, policies and procedures and regulatory requirements.  

Assures department meets all regulatory time frames on CM.

Develops and implements departmental policies and procedures.  

Develops and maintains departmental statistical and performance reports.  

Develops, implements and monitors performance standards.

Develops and maintains effective communication mechanisms at various levels of the organization and with external organizations.

Develop and maintain departmental budgets in line with organizational goals.  Assure operational effectiveness to meet MCR targets and optimize health care resource utilization. 

Assures appropriate staff support of Utilization Management and other relevant committees.  

Supports the maintenance of positive relationships between L.A. Care and external groups.

Identifies and implements, with approval, programs that improve the provision of services to members.  

Supports Clinical Assurance/Delegation Oversight in the measurement and analysis of delegated Participating Physician Group (PPG) functions.

 

Duties Continued

Internal Health Plan Operational Management: 
Proactively identifies and implements operational modifications to enhance departmental performance.  

Develops and implements operational business plans and departmental objectives to support organization strategies and tactics.  

Interfaces with and collaborates with other service areas to assure optimal service delivery to members, compliance, and efficiency. Maintain compliance with all internal audits.

Human Resource Management: 
Develops goals, objectives and actions plans for assigned staff which includes full management responsibility for the hiring, performance reviews, salary reviews and disciplinary matters for direct reporting employees.

Develops and maintains a culturally sensitive work environment that promotes staff growth and education. 

Completes performance appraisals in accordance with establishe