Director of Medial Management and Quality Improvement

Location: Southern, CA
Date Posted: 03-26-2018
Director of Medical Management and Quality Improvement

About the position:

Under the direction of the SR. Director of Medical Management and Quality, the Director of Case Management and Clinical Quality Improvement, is responsible for the oversight of the Case Management programs, including the Model of Care. Additionally, the position is responsible for analyzing, planning, facilitating, and coordinating the development and implementation of the clinical quality improvement activities and programs that fulfill the company, and regulatory quality improvement standards and commitments. Oversight includes programs that address clinical quality improvement related to HEDIS, STARS, and P4P programs, as well as department performance.

Job Responsibilities:
  • Implements and manages health care management’s utilization, cost, and quality objectives.
  • Ensures program compliance and identifies opportunities to improve customer service and quality outcomes.
  • Demonstrates leadership abilities in a clinical operations environment
  • Develop and meet contractual reporting obligations related to area of accountability and participate as a subject matter expert on contract changes and deliverables, as required to meet contractual and customer expectations.
  • Development and continual review and revision of all processes, policies and procedures with the department.
  • Develops reports and metrics to be utilized for productivity, adherence and outcome measurements.
  • Ensure departments optimize workflow efficiencies to meet company objectives.
  • Provides supervision, guidance and mentoring to managers and staff.
  • Ability to communicate effectively with a wide range of individuals, both internal and external.
  • In-depth knowledge of managed care operations, benefit design and UM/CM techniques.
  • Ability to work with internal customers to facilitate programs.
  • Provides input to business leaders and leadership regarding program enhancements, operational improvement and potential benefits of the improvements.

Job Requirements:
  • BSN Required; MSN or MBA preferred
  • 5+ years Case Management Experience, Model of Care Case Management experience desired
  • 6+ years relevant experience in managed care, health plan, or healthcare administration
  • Medicaid/ Medicare experience required
  • HEDIS and NCQA experience required
  • Experience managing 25 + direct reports and indirect reports required
  • Reporting, analytics, and developing actionable tasks
  • Advanced knowledge of Medicare and Medicaid programs as well as established clinical acumen
  • Advanced knowledge of commercial health plan programs
  • Advanced computer skills with proficiency in MS Office applications especially MS Excel
  • Proven capability to work with people at all levels in an organization
  • Excellent training and presentation skills with solid communication capabilities and practices, oral and written
  • Strong interpersonal, verbal, written, and administrative skills
  • Demonstrated effective organizational skills
  • Excellent communication, writing, proofreading and grammar skills
  • Strong attention to detail and accuracy, excellent Evaluative and Analytical skills
  • Strong teamwork, interpersonal and customer service skills
  • Familiarity with statistics, especially around predictive modeling and risk
  • Ability to understand complex applications and derive solutions

  • CA Registered Nurse
  • CCM certification strongly preferred
  • NAHQ Certification strong preferred

this job portal is powered by CATS