Director, Medical Management

SUMMARY:   

The Director will lead and participate on cross-functional teams to develop and operationalize comprehensive programs to achieve desired strategic objectives. This role will collaborate with highly clinical individuals and executive leadership including: physicians, nurses, pharmacists and others. This role will identify opportunities and facilitate process standardization while optimizing technology efficiencies and reporting capabilities in a metric driven environment.  The Director is responsible for the assessment, planning, coordination, development and direction of Care Coordination and Case Management initiatives.

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.

• Presents strategic recommendations to leadership based on internal and external drivers and trends, support strategic initiatives and effectively manages and completes strategic objectives and department priorities.
• Conducts needs analyses, identifies gaps and develops program components to mitigate identified gaps.
• Creatively and innovatively designs, develops, implements, evaluates and revises Case Management programs to incorporate current research and evidence based best practices ensuring optimum outcomes.
• Provide vision and leadership in the development of medical cost containment solutions by optimizing vendors and internal initiatives and developing programs.
• Provide guidance, support and oversight for ongoing changes in medical and drug coding standards.
• Provides expertise on review of data and reports to assist in developing and improving medical management strategies. 
• Provides ongoing evaluation and assessment of facility practices and industry changes to ensure enterprise remains current in Case Management processes.
• Align corporate claims handling philosophy and lead team in support of department initiatives and strategies in cost containment, medical management, customer service, training and quality, etc. 
• Provide vision, leadership, planning, project coordination and management for the development of a cost-effective department while concurrently facilitating efficient operations to meet current and future business needs within the organization.
• Represent company in community and industry, programs and conferences.
• Upon request, function as the department head in the absence of the executive.
• Participate in the development of programs as a strategic partner that supports the company plan.
• Participate in development of annual departmental budget, monitor budget and identify budget discrepancies.  Research cause and make recommendations.
• Responsibility for balancing workload to optimize the effectiveness of the department.

EDUCATION AND EXPERIENCE 

• Bachelor’s degree in nursing, healthcare or related field required. Master’s Degree preferred. CCM preferred.
• Certification or progress toward Nursing licensure certification is highly preferred and encouraged.
• Ten (1) years of progressively more responsible experience in an insurance environment with demonstrated technical experience that provides the necessary knowledge, skills and abilities. 
• Five (5) years in workers compensation insurance administration.
• Five (5) years of management experience in a claims, medical, or nurse case management environment required. 
• Bilingual skills preferred.

QUALIFICATIONS

• To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED:

• Extensive knowledge of workers compensation laws, regulatory authorities, compliance requirements, industry trends and their impact.
• Ability to make recommendations significantly changing, interpreting or developing important policies or programs.
• Strong organizational skills and be able to operate in a team environment. 
• Extensive knowledge of medical and legal terminology. 
• Advanced technical knowledge of insurance administration, claims management or relevant insurance expertise.
• Must demonstrate leadership ability and team building skills to effectively supervise professional and non-professional staff and interact with all levels of management.
• Ability to work with and empower others on a collaborative basis to ensure success of unit team.
• Ability to effectively exchange information, in verbal or written form, by sharing ide