Director, Care Management (Medicaid, Hybrid)

Awarded a Healthiest Employer, Blue Cross Blue Shield of Arizona aims to fulfill its mission to inspire health and make it easy. AZ Blue offers a variety of health insurance products and services to meet the diverse needs of individuals, families, and small and large businesses as well as providing information and tools to help individuals make better health decisions.

Purpose of the job

Leads and manages all care management functions within the Medicaid Segment, to include but not limited to physical health, behavioral health, pediatric, and maternal care through an integrated care model to ensure compliance with all regulatory agencies and accrediting organizations. Evaluates and ensures that all organizational care management programs and resources are used appropriately and effectively, and oversees the collection, analysis, and reporting of financial and utilization data related to all utilization management and performance improvement activities. Accountable for achieving established performance targets through actively engaging multiple disciplines and professional staff and has responsibilities for managing people, relationships, and processes in order to achieve maximized results. Ensures the care management department achieves its goals and objectives by engaging internal and external stakeholders in care management processes across the Medicaid Segment. Promotes interdisciplinary collaboration, fosters teamwork across the organization, and champions performance improvement and goal achievement.

REQUIRED QUALIFICATIONS

• 5 years of management experience
• 5 years of managed care, health services, health outcomes, or disease management experience, specifically in developing and implementing clinical programs
• 3 years of experience with the Medicaid Care Management Operations
• 3 years of experience with accreditation standards

• Bachelor’s degree in healthcare, healthcare administration, business administration or related field

• Required Licenses
  • Active, current, and unrestricted license to practice in the State of Arizona (a state in the United States) as a health professional, including RN, LCSW, LPC, LISAC LMFT, Psy.D. or Ph.D.
  • If the selected candidate does not possess an Arizona license, they are required before their date of hire to obtain a temporary valid unrestricted Arizona license to practice, while they work to obtain their Arizona license.

• N/A

PREFERRED QUALIFICATIONS

• 7 years of management experience
• 7 years of clinical experience in a primary care field
• 7 years of managed care, health services, health outcomes, or disease management experience, specifically in developing and implementing clinical programs
• 3 years of experience with the state of Arizona’s health care plan known as AHCCCS
• 3 years of experience with NCQA accreditation standards

• Master’s degree in healthcare, healthcare administration, business administration or related field N/A

• N/A

• N/A

ESSENTIAL job functions AND RESPONSIBILITIES

• Ensures care management compliance as defined by AHCCCS and NCQA are met and maintained.
• Leads and manages the care management staff in order to provide quality focused cost-effective interventions to all patients across the continuum of care.
• Establishes collaborative relationships with provider agencies, hospital care coordination teams, skilled nursing facilities, and the health plan clinical teams to meet the clinical and social service needs of the patient population.
• Oversees the day-to-day operations of the care management department and the use of systems to identify individuals and populations at risk and/or those in need of complex and chronic care case management.
• Works collaboratively with clinical leaders in developing and implementing programs and initiatives to address those issues.
• Monitors care management program effectiveness and efficiency and adjusts accordingly.
• Consults with the Staff VP of Clinical Operations and the CMO on the development of care management process and outcome analysis and reporting.
• Introduces and monitors care management tools and strategies and leverage technological solutions when possible.
• Maintains good vendor/client relationships where appropriate.
• Communicate health care and health management industry methodologies used for health management programs; develop and execute plans and articulate vision.
• Identify strategic dir