Director, Case Management Nurse Management

Your Role

The Director of Transitional Care Services reporting to the Sr Director, Population Health Management, will work to implement whole person integrated healthcare by leading Care Management for the MediCal member population. This role will provide leadership, direction, and oversight to our Medi-Cal Transitional Care Services team and ensure that our beneficiaries receive case management interventions and linkages to essential services while residing in an inpatient setting and post-discharge. Services will include linkage to PCPs and specialist and linkage to other supportive services such as CalAIM Enhanced Care Management, CalAIM Community Supports, the Community Health Worker Benefit and Long-Term Services and Supports. This leader will support the Population Health program designed to engage members, reduce disparities and gaps in care, and improve quality for our Medi-Cal members.  This position will drive member experience and engagement, improvement in the overall health of Blue Shield of California members, and affordability and efficiency. The Director contributes to the overall strategy and goals of the Medical Care Solutions organization.  This role is being created in compliance with the MediCal mandate requirement outlined by the Cal-AIM Population Health Management program. 

Your Work

In this role, you will:

• Be accountable for annual strategic planning, resource planning to ensure appropriate resources are allocated to projects and are appropriately calculated in the PHM transitional care services department budget                                                                  
• Act as a change agent for Population Health Management to improve performance results, provides organizational effectiveness leadership to achieve department goals (people/process/technology), with a focus on optimizing Transitional 
• Be responsible for the care management team that focuses on high quality patient care and other high member touch programs within Medi-Cal line of business, with TCS integrated as a core function to support timeless coordination during inpatient stays and post-discharge outreach.
• Establish strong partnerships across the organization including Utilization Management, Human Resources, Planning & Finance, Control Tower, Program Delivery (Project Management Office) and IT.
• Coordinate PHM transitional care services team readiness for new benefits implementations with the goal of ensuring all members have access to the right care, at the right time, and at the right benefit at the right price on their effective date and all operational metrics are within agreed upon service levels.
• Develop and maintain a training and learning development plan
• Ensure ongoing business process management using continuous process improvement practices, and implementation of technology to drive greater efficiency, productivity and customer experience
• Ensure a culture of affordability, drives leadership principles among people managers, and ensures team actions are in place to make Blue Shield a great place to work
• Responsible for driving the strategic outcome of the Medi-Cal line of business for PHM Transitional Care Services.  This includes the evaluation of data from multiple sources, designing and refining care coordination programs in conjunction with other clinical leaders, and reviewing key performance indicators to inform ongoing program improvement, staffing alignment, and member engagement strategies.
• Responsible for partnering with MediCal leadership and other market leadership to design, develop and implement key initiatives that will enhance the value and performance of the Medi-Cal product by developing products, services, processes or systems that are new to Blue Shield. This includes identifying opportunities within PHM Transitional Care Services to pilot or scale approaches that improved care coordination, member outcomes, and operational efficiency.
• Responsible for key PHM Transitional Care Services metrics related to compliance and contractual obligations by ensuring teams are within compliance in accordance with all regulations and contractual obligations. 
• Develop prospective approach to maintaining audit readiness, maintaining documentation, workflows, and reporting practices that demonstrate consistent compliance and program integrity. 
• Serve as a representative of PHM Transitional Care Services department for areas of responsibility.
• Lead as a subject matter expert in all regulatory requirements and operational processes related to Medi-Cal care management, with a focus on transitions of care and coordination across settings. 
• Maintain staffing and development of PHM Transitional Care Services clinical and non-clinical staff. Works with Medi-Cal leadership and market leaders to ensure ap