Nurse Executive Job Opportunities
Updated August 10, 2008

• Director, Health Services
  Austin, TX and Birmingham, AL

Primary Function

Under the leadership of the Vice President, Health Services is Responsible for the planning, development, implementation and management of the Utilization, Chronic Care and Rapid Response programs. Monitors and implements appropriate interventions to assure achieving cost effective and quality outcomes for membership served within approved Medical Budget. Collaborates with the Sr. Medical Director and Vice President, Health Services to evaluate the effectiveness and clinical outcomes of the Chronic Care Improvement Program.

 

Responsibilities

• Plans, organizes and directs the development and implementation of Utilization Review, Chronic Care and Rapid Response unit activities.
• Ensures staff receive appropriate orientation, training and ongoing professional development to meet the needs of the population served. Assists in identifying and establishing educational needs, developing and implementing an education plan, completing educational programs, and monitoring and evaluating the status towards achieving department goals and objectives.
• Assists in the development, implementation, monitoring and ongoing improvement of the Chronic Care department, which includes the functions of rapid response, intensive case management and disease management activities.
• Establishes performance and productivity standards for all associates. Communicates expectations and individual performance quarterly. Ensures that Chronic Care program enrollment and outreach productivity and performance standards are met. Continuously strives to improve departmental operational efficiencies and workflows.
• Assists the Vice President in preparing the Health Services budget. Monitors and implements appropriate intervention to achieve operational budge targets.
• Coaches, counsels and implements appropriate disciplinary action within guidelines established by Human Resources.
• Assures congruence and alignment between health management programs and any related medical practice guidelines, utilization management criteria and case management programs. Ensures that medical guidelines are current and valid and communicated to providers and members as appropriate.
• Develops implements and revises policies and procedures required to ensure compliance to NCQA, URAC, and CMS requirements. Audits compliance to standards quarterly and implements appropriate interventions to achieve departmental goals.
• Creates and supports an environment which fosters teamwork, cooperation, respect and diversity. Establishes and maintains positive communication and professional demeanor with health plan employees and clients at all times. Strives to improve associate morale and retention. Demonstrates and supports commitment to corporate goals and mission.
• Completes QI work plan assignments on time and prepares reports of activities to PAC and QIC. Prepares annual program description and program evaluation noting opportunities for improvement. Participates and presents periodic updates as requested to Leadership Team.
• Assists in the annual evaluation of the Consumer Assessment of HealthPlan (CAHPS) member satisfaction survey and Healthcare Employer Data Information Set (HEDIS) results and the Network Provider survey. Identifies opportunities for improvement in process and care and service to members and providers.
• Maintains good rapport with participating network physicians, hospital personnel, social services, ancillary agencies, etc. Acts as health plan liaison with outside entities and regulatory agencies when required.
• Maintains all necessary educational requirements for required licensure and certifications.

Supervisory Responsibilities

Hires, manages and evaluates direct reports and in-direct reports as necessary

 

Key Competency Success Factors

• Budgetary Responsibility - Develop and maintains department budget. Seeks opportunities to contain cost and increase profitability.
• Corporate Financial Performance – Assists in the establishment and achievement of business objectives for the area of responsibility based upon company’s overall strategic plan and operating goals for this year.
• Performance Management – Develops specific and measurable performance standards for all direct reports. Holds self and others accountable to goals and standards of department and company.
• Employee Training & Development – Guides and encourages career development, conducts timely performance evaluations and provides open/ongoing constructive feedback to all direct reports.
• Leadership Skills – Leads by example: Sets an example of personal performance, which encourages excellence and integrity. Role models Mission and Values and promotes excellence in customer service through personal actions.
• Job Knowledge – Maintains current knowledge of and applies all applicable licensing, regulatory and industry standards. Keeps abreast of current industry trends.
• Communication Skills – Writes, speaks and presents clearly and concisely. Is thoroughly prepared prior to beginning any negotiation or conflict resolution process.
• Regulatory and Delegation Compliance - Assesses department work quality and develops/implements process improvements to improve and achieve regulatory and oversight compliance.
• Analytical Skills – Analyzes data and makes sound, logical and timely decisions. Establishes priorities and sets long and short term goals

Position Qualifications/Requirements

Education and Training: RN license required, Bachelor’s or Masters degree preferred

Experience: Minimum of ten years clinical experience with at least five years in managed care and 5 years of progressive management experience

License, Registration or Certifications: Current RN license in the State of Texas or Alabama. CCM certified or eligible for certification within 12 months of hire. Valid drivers’ license.

Computer Skills: Proficient in Microsoft Word, Excel, PowerPoint and Outlook.

 

For more information, please contact David Mara at 804.527.1905. To see additional opportunities, go to www.nexushc.com.

 

 

• Director, Compliance and Regulatory Affairs
  Columbia, SC

Job Description

 

Position Purpose

Perform duties to direct all aspects of compliance functions of the health plan, negotiate and handle the relationship with the Medicaid agency, the insurance agency in the State and delegate entities, aid in formulating and administering organization policies and procedure and participates in business development opportunities for the company.

 

Position Qualification Requirements

 

Knowledge/Experience

Advanced knowledge of a specialized or technical field such as management, public policy, government affairs. Equivalent to a four (4) year college education. Advanced degree preferred. Over five years up to and including seven years of management experience. Experience in a managed care or insurance environment.

 

Skills/Competencies

Apply principles of logical or scientific thinking to define problems, collect data, establish facts, and draw valid conclusions. Deal with several abstract and concrete variables. Perform advanced functions of mathematics, algebra and statistics. Apply mathematical operations to frequency distributions, reliability and validity of tests, normal curve, analysis of variance, correlation techniques and factor analysis. Perform reading, writing and speaking at an advanced level. Read periodicals, journals, manuals. Prepare business letters, expositions, summaries and reports using prescribed format and conforming to all rules of punctuation, grammar, diction and style. Participate in panel discussions and debates, and speak extemporaneously on a variety of subjects. Ability to use computer systems for the management, reporting and presentation of information, as well as correspondence. Ability to travel.

 

Principal Functions and Accountabilities

 

Leadership

Confer with President and other senior staff to review achievements and discuss required changes in goals or objectives resulting from current status and conditions. Develop, implement and maintain production and quality standards for the health plan.

 

Significant Duties

Research and stay abreast of state and federal regulatory compliance issues and serve as lead of the integration of compliance projects at the health plan level.

 

Needs Analysis and Planning

Evaluates and implements changes to service functions and performance in relation to company mission, philosophy objectives and policies.

 

Strategic Planning

Participate in formulating and administering company policies and developing long-range goals and objectives. In support of the company’s strategic plan, establish the department’s strategic vision, objectives and attendant policies and procedures for the organization. Partner with business unit leaders to identify and prioritize needs of the organization. Evaluate current procedures and practices for accomplishing the organization and department’s objectives to develop and implement improved procedures and practices and to ensure compliance with all related laws, regulations and executive orders.

 

Standardize Applications and Processes

Research and incorporate best practices into operations. Assures that department functions and responsibilities are coordinated with other operating departments of the Plan and Corporate. Responsible for the statistical analysis of utilization data. Participates in NCQA accreditation of the Plan.

 

Budgeting

Monitor and analyze costs and prepare the annual departmental budget

 

Cross-Functional Activities

Chair, participate in, attend, and plan/coordinate, staff, departmental, committee, sub-committee, community, State and other activities, meetings and seminars. Serve on senior executive and management committees, as well as directing special projects or studies.

 

For more information, call David Mara at 804.527.1905. To view additional opportunities, go to www.nexushc.com
 

 

• Director Network Development
  Des Moines, IA
  Principal Financial Group

• Experience with PPO Network providers
• Strong relationship building skills
• Contract experience
• Strategic thinker

Responsibilities

Provide strategic leadership to the im

plementation of medical network, medical provider and medical vendor contracting strategies for assigned region.

 

Qualifications

Bachelor's degree or equivalent plus 8-10 years related work experience required. ICA - International Claim Association (ICA), Fellow, Life Management Institute - LOMA (FLMI), Health Insurance Association of America (HIAA), or Academy for Healthcare Management (AHM) designations preferred. Advanced knowledge of business unit products and basic knowledge of company products required. Must have excellent planning/organizational, problem-solving, analytical, presentation, and oral and written communication skills, as well as advanced math skills. Excellent leadership skills required, along with excellent time management and decision-making skills. Must be able to maintain a high degree of accuracy. Advanced computer skills and knowledge of business unit applications required. Ability to maintain confidentiality essential. Travel required 30% including overnight stays.

For more information, please contact David Mara at 804.527.1905.   For additional opportunities, go to www.nexushc.com

 

 

• Coordinator Quality Management
  Location:  Tampa, FL

Responsibilities

 

JOB SUMMARY
The Quality Management Coordinator is responsible in conjunction with management for developing, coordinating, implementing, and evaluating the continuous quality improvement activities throughout the company according to the established Quality Management program.  In collaboration with and under the direction management, the Quality Management Coordinator establishes indicators for monitoring and evaluating the full spectrum of care and services provided to members for quality, appropriateness, continuous improvement and satisfaction.  The Quality Management Coordinator provides education in the area of quality management to all departments and assists in ensuring compliance with regulatory and accrediting organizations.

 

PRIMARY RESPONSIBILITIES

1. Designs and implements quality improvement studies including selection of valid and reliable indicators and coordinates monitoring and evaluation activities.
2. Analyzes data and prepares concise, accurate and meaningful quality management reports in accordance with Company procedures.
3. Actively participates in intradepartmental quality management improvement teams as appointed.
4. Educates AMERIGROUP associates about the QM process.
5. Assists in defining opportunities for improvement identified through analysis of trends and communicates these appropriately.
6. Assists in the preparation for the Quality Improvement Council, Quality Management Committee and other QM related committee meetings.
7. Prepares QM department responses for RFIs and RFPs.
8. Responsible for maintaining quality management documents, case files and correspondence in an organized, confidential and secure manner.
9. Conducts, as appropriate, oversight audits for all nationally delegated vendors.
10. Communicates significant findings, including potential risk management issues to the AVP Quality Management as indicated in a timely manner.
11. Assists with coordinating HEDIS preparation and completion.
12. Assists with coordinating HEDIS Improvement Activities.
13. Assists with coordinating Member Satisfaction reporting Improvement activities.
14. Other duties as requested or assigned.

JOB REQUIREMENTS

Education and Experience:

• Bachelor’s degree required.
• 2-3 years experience in quality improvement, risk management and/or utilization review in a managed care setting.
• Knowledge of local and national QM and regulatory standards preferred, including NCQA and HEDIS reporting.

Certification and Licensure

• Current professional licensure LPN or RN (RN preferred).
• CPHQ preferred.

Knowledge and Skills

• Computer literate including word processing, spreadsheets and database management skills.
• Excellent verbal and written communication skills.
• Strong decision making skills.
• Demonstrates organizational skills.
• Ability to work self directed and in work groups.
• Ability to interact with all relevant components of the health care system.
• Appreciation of cultural diversity and sensitivity towards target population.

Physical Requirements

• Must be able to operate a computer.
• Must be able to operate a telephone.

Equal Employment Opportunity

 

In accordance with state and federal laws, employment offers are tendered solely on the basis of qualifications without regard to race, religion, color, national origin, age, sex, marital status, sexual orientation, handicap (including disabled veterans) or Vietnam Era veteran status.

 

AMERIGROUP administers pre-employment drug testing as a condition of employment and a satisfactory criminal history background report. 

 

For more information go to www.amerigroupcorp.com or call Jason Alderman at 813-830-6982.
 

 

• Vice President of Medical Management (VPMM)
  Metairie, LA

Position Purpose

 

The Vice President of Medical Management is administratively responsible for the oversight of the Medical Management department of the health plan.  The VPMM provides leadership, management support, strategic planning, and overall direction for both the clinical and non-clinical functions of the Medical Management department.

 

Scope of Position

 

The Vice President of Medical Management is responsible for developing, coordinating, and implementing medical management programs for the health plan, that result in improved health outcomes for members.  These initiatives include the establishment of indicators for monitoring and evaluating quality care, appropriateness of care, continuous improvement, member satisfaction, utilization, and case management across the continuum of care to members.

 

Principal Responsibilities

• Directs and provides leadership for designing, developing and implementing Medical Management Programs to meet the demographic and epidemiological needs of the plan membership.
• Identifies annual goals and objectives to achieve appropriate reductions in medical expenses that correlate with continuous performance improvement efforts and implements best practices and benchmarks to target performance goals.
• Utilizes timely and meaningful financial/utilization reports to identify opportunities for decreasing medical expense.
• Develops and continually refines operational processes within the healthcare delivery system to promote system-wide best practices and produces analysis documents to guide strategic planning.
• Ensures the integrity of processes and reports associated with the tactical initiatives.
• Collaborates with the VPMA in developing and implementing clinical programs in accordance with the goals of the health plan's mission, vision and values, the needs of the health plan, federal and state regulatory requirements and URAC standards.
• Evaluates programs regularly.
• Ensures that medical management activities are contracted, reviewed and reported according to established criteria.
• Develops medical management policy, procedures and guidelines to ensure compliance with specific medical management standards.
• Serves as a clinical leader to Medical Management associates.
• Works collaboratively with key health care professionals toward identification of opportunities for improvement, trend analysis, education and development of appropriate action plans for problem resolution.
• Analyzes data and evaluates necessary plan services for cost containment.
• Develops the annual operating and capital budgets to sufficiently meet departmental needs and ensures that department stays within budget and accounts for variances.
• Ensures compliance with state reporting on utilization management activities for accuracy.
• Supports and participates in quality initiatives and activities including clinical indicators reporting, focus studies and HEDIS reporting.
• Supports and participates in disease management program initiatives.
• Promotes plan-wide understanding, communication, and coordination of Medical Management Programs.
• Explores alternatives in the UM/CM process.
• Mentors and provides guidance to team members and subordinates.
• Assists the VPMA with development of the Medical Management Committee agenda and reports for the meeting.
• Performs other duties as assigned.

Education

Required: Bachelors Degree in Nursing, Business Administration, Health Administration, or equivalent work experience.

Preferred: Advanced degree (MSN, MPH, MPA, or MSW or related or MBA with Health Care Concentration) Certification in Healthcare Quality (CPHQ) preferred.

 

Years and Type of Experience

 

Required:

• Thorough understanding of managed care principles, models, and financing
• Must have at least five years of demonstrated medical management experience in a managed care or hospital care setting including utilization management, quality management, disease management, and medical management or other related MCO departments/functions.
• Must have at least five years of management experience, preferably at an executive level.
• HEDIS and URAC experience preferred.
• Knowledge of Utilization Management targets.
• Statistical reporting experience preferred.

Knowledge and Technical Skills

Mastery of computer software, including but not limited to:

• Microsoft Word, Excel (or other spreadsheet software), and Power Point preferred
• Knowledge of MACESS, Amisys, or other managed care claims, UM, or QM software highly preferred

Licensure/Certification

Required: RN or LCSW
Preferred: Certified Case Manager (CCM), Certification in Healthcare Quality (CPHQ)
 

For more information contact David Mara at 804-527-1905.  For additional opportunities go to www.nexhushc.com
 

 
 

• CARE MANAGER II

Health Net, Inc. (NYSE: HNT) is among the nation’s largest publicly traded managed health care companies. Health Net’s mission is to help people be healthy, secure and comfortable. The company’s POS, HMO, insured PPO, behavioral health and government contracts subsidiaries provide health benefits to more than 7 million individuals. For more information on Health Net, Inc., please visit the company’s Web site at www.healthnet.com

 

JOB SUMMARY: CARE MANAGER II - Onsite Concurrent Review w/Integrated

Telecommuting Options

 

The Care Manager II is responsible for providing care management services to beneficiaries with planned admissions to acute care hospitals, or to those transitioning from case management or disease management programs.  Systematically identifies and addresses fragmented care for patients with acute, real-time needs and tailors interventions and services to fill gaps and produce optimal clinical outcomes.

 

May also conduct Quality Assurance audits, monitor and oversee workflow, review and maintain policies and procedures, and perform system testing of modifications and enhancements.

 

Location: Tigard, Oregon

 

ESSENTIAL DUTIES AND RESPONSIBILITIES

 

Pre-Admission Counseling

• Contacts patients with upcoming hospital admissions and discusses expectations.
• Assesses patient’s condition to understand illness or injury and evaluate ability to follow treatment plan.
• Advises patients of probable length of stay and helps anticipate and arrange for services at discharge.

Admission Care

• Works with physicians and hospitals to enforce treatment plans and orders.
• Ensures patient receives specialty care and tests as ordered.
• Contacts medical team members to discuss patient’s course of progress and needs.
• Arranges for and coordinates health care team services, avoiding duplication and conserving benefit dollars.
• Evaluates need for and authorizes equipment, supplies, services.
• Identifies problems and instructs patient and family in proper care and refers patient back to physician or other health care team members.
• Identifies plateaus, improvements, regressions and depressions, and counsels accordingly.

Coordination of Care

• Conducts hospital visits.
• Confers with physician to clarify diagnosis, prognosis, therapies, daily living activities, and to share information.
• Authorizes recommended modalities of treatment. Investigates and suggests alternatives.
• Documents case summary in Transitional Care Plan and shares appropriately with beneficiaries and providers.
• Facilitates beneficiary transfers among regions and collaborates with military liaison to minimize disruption care or services.
• Coordinates basic benefit. Identifies and submits modifications, requests for exceptions or special programs.

Coordination of Financial Services

• Assesses patient’s benefit plan coverage and limitations.
• Negotiates rates for provider services by contacting multiple providers and comparing specialty item costs, researching and identifying required equipment, and pursuing contracts. Suggests medical alternatives that accomplish treatment plan goals.

Post Discharge Follow-up

• Contacts patients within 48 hours of discharge to ensure sufficient support for full recovery.
• Ensures proper receipt of equipment, home health and other services.
• Assesses compliance with medications and follow-up appointments.
• Assists patient in coordinating transportation and other basic needs, and in navigating the health care system.

Associate Training

Organizes, schedules and conducts program and skill training for Care Management associates.

Identifies and maintains ongoing training needs and designs training plans.

Develops care management policies and procedures, and facilitates and recommends process improvements.

 

REQUIREMENTS:
Education:
Graduate of Nursing program, BSN Degree preferred.

 

Certification/License:

Valid and active State of Oregon Registered Nurse licensure required.

State of Oregon Driver’s License

 

Experience:
Five years clinical experience in a health care environment; including Care Coordination, Nurse Advice/Triage, Case or Disease Management.
Managed care experience preferred.

Internal candidates must have functioned as a Case Manager I and received a satisfactory score on the Advancement Exam.

 

Knowledge, Skills & Abilities:

• Exceptional written and oral communication skills.
• Demonstrated ability to assess, evaluate and interpret medical information.
• Skilled in computer operation with proficiency in Microsoft Office Word. Excellent Interpersonal skills and ability to work effectively and independently.
• High level of understanding of community resources, treatment options, home health availability, funding options and special programs. OR Any combination of academic education, professional training or work experience, which demonstrates the ability to perform the duties of the position

For immediate consideration apply at: www.careersathealthnet.com.
Click on Find a Career; locate this position by Job Number 08000202; click on Search; click on the job title when it appears (toward bottom of page); click on the Apply On Line button.
 
On behalf of Health Net, thank you for your application.

 

Health Net, Inc. supports a drug-free work environment and requires pre-employment background and drug screening.

 

Health Net and its subsidiaries are an Equal opportunity/Affirmative Action
Employer M/F/V/D.
 

 

• Senior Manager, Utilization Management

Keystone Mercy Health Plan is Pennsylvania's largest Medical Assistance (Medicaid) managed care health plan, serving more than 273,000 Medical Assistance recipients in southeastern Pennsylvania, including Bucks, Chester, Delaware, Montgomery and Philadelphia counties. Headquartered just outside of Philadelphia near the International Airport, Keystone Mercy Health Plan is a mission-driven health care ministry of the Sisters of Mercy with more than 20 years of experience. Its corporate parent partners are Mercy Health System and Keystone Health Plan First, a subsidiary of Independence Blue Cross. Our company Web site, www.KMHP.com, tells our story.

Equal opportunity employer. 

Under the supervision of the Sr. Director of Utilization Management, the Senior Manager is responsible for

• Providing oversight and daily administrative management of the Utilization Management Service Team.
• Maintaining the Plan’s compliance with HealthChoices and NCQA/URAC standards related to Utilization Review. This responsibility includes all interdepartmental and intradepartmental coordination, communication, education and committee structure and support.
• Reviewing existing Utilization Management policies and assisting in the development and implementation of new policies and procedures impacting Utilization Management. 
• Meeting budget, organizational and departmental goals.

 Requirements:

• Registered Nurse graduated from an accredited diploma, Associate’s degree or Bachelor’s degree program
• Bachelor’s degree in Nursing or Health-related field preferred
• Minimum 8-10 years progressively responsible experience in a clinical environment, including utilization management, case management, appeals and/or discharge planning experience
• Previous experience in managed care
• Medical assistance experience preferred
• Minimum of 4 years management experience
• Current Pennsylvania Registered Nurse License
• Valid driver’s license required (and reliable transportation for offsite work-related activities)

 Excellent benefits/salary package, including no city wage tax for non-Phila. residents, 9 paid holidays off, tuition remission, pension plan, 3 weeks vacation to start and compressed workweeks, PLUS a Management Incentive Program of 9-13%.

Qualified candidates, please send resume to humanresources@kmhp.com

 

• Medical Management Services Director

Provides leadership and direction to the Medical Management Department, including Care Coordination, Case Management, Third Party Administration, Grievances and Appeals, and Quality Improvement.

Requirements:

• Current Oregon RN License
• BS in Nursing
• 5 years clinical nursing experience
• 5 years managed care experience
• 5 years of healthcare management experience at a supervisory or managerial level
• Excellent verbal and written communication skills, as well as, outstanding problem solving, organizational and leadership skills.
• Strong project management skills and the ability to lead and motivate a large diverse staff and interdisciplinary teams.

Duties and Responsibilities:   

• Supervision of Quality Improvement department
• Performance of internal audits
• Supervision of staff training and education.
• Member education.
• Oversight of Third Party Administration activities including updating policies and procedures.
• Oversight of Appeals and Grievance processes and procedures, including updating policies and procedures.
• Maintain high level understanding of Medicare and OHP benefits packages.
• Manage office staff of over 12 people of various disciplines including nurse case managers, compliance personnel, and administrative staff.  Responsible for scheduling staff, resolving issues, determining staffing needs (hiring and firing), employee reviews, orientation and training of staff.
• Monitor and review the Exceptional Needs Care Coordinator services provided to members.
• Act as liaison to community resources and introduce staff to new medical service providers.
• Audit and review member charts, filing, logging and storage policies and procedures.
• Communicate with local service area companies through weekly meetings and conference calls to ensure coordination of members’ benefits, and that policies and procedures are being followed.
• Assist the Chief Medical Officer and Medical Director with special projects as needed.
• Help manage conversion to electronic medical record system.
• Develop policies, procedures and training manuals for all of the areas of responsibility.

We offer a competitive salary based on experience and a comprehensive benefits package which includes, Medical, Dental and Vision insurance, Life insurance, Flexible Spending Accounts, Simple IRA with matching (no waiting period), Holidays and PTO. Relocation assistance is available for this position.

This position is located in Roseburg, OR, which is in Southern Oregon. Roseburg is a fabulous community located on the famed Umpqua River, which is one hour from the Cascade Mountains and one hour from the Pacific Ocean. The Umpqua River Valley is surrounded by beautiful evergreen hills and provides a multitude of outdoor activities such as mountain biking, hiking, camping, boating, fishing, kayaking, canoeing, tennis, golf, and much more. Umpqua Valley is also becoming known as a quality wine growing and making region. We boast well over 10 quality wine labels and winemaking is quickly becoming an important industry to this area. This area continues to grow from our new industry and the appeal of the beautiful area. Real estate in Roseburg, OR is still reasonable and many people have been relocating from more expensive areas on the West Coast to take advantage of the real estate opportunities. For more information on Roseburg you can visit www.roseburgareachamber.org.
If you are interested in this opportunity please send your resume to ksandfort@dcipa.com.
 

 

• Nurse Case Manager
  Medicare/Medicaid

Our company is experiencing rapid growth and we have an excellent opportunity for an experienced nurse that wants regular hours Mon.-Fri. 8-5. 

Working with clients and local health care providers the Nurse Case Manager position is central to the care delivery system in coordinating health services for health plan members.  

Requirements:

• Currently licensed RN in Oregon
• 5 years of recent experience in a variety of nursing positions
• Experience in case management is helpful.
• AS or BS in nursing preferred.
• Microsoft Word, Excel, Outlook and keyboarding skills required for communication, documentation, research and claims.
• Excellent verbal and written communication skills.
• Ability to communicate with people on various levels from different backgrounds.
• Demonstrate a good understanding of HIPAA rules and regulations and an ability to maintain confidentiality.

Duties and Responsibilities:

• Review and process requests for services for both Medicare and Medicaid members.
• Request prior authorizations with appropriate documentation for procedures, medications, equipment, hospitalizations, and admissions into skilled nursing facilities (SNF’s).  Approve authorizations per the Medical Director’s guidelines and deny requests at the Medical Director’s discretion.
• Perform case reviews in order to monitor and coordinate care between the members and the providers, pharmacies, DME suppliers, care facilities, hospitals, home health, case worker, mental health and chemical dependency agencies. This will include participating in and acting as liaison at case conferences at the Hospital and local nursing facilities.
• Track U/R and SNF admissions, appeals, member’s calls to our company, stop loss cases and other information as requested by insurance companies and the medical director.
• Communicate effectively with insurance companies, providers and their staff, suppliers, pharmacies, and other service providers by participating in meetings and telephone conferences on a weekly basis as well as handling daily inquiries.

• Participate in member case management conferences and community meetings with the local SNF’s, providers and state agencies.  This may require occasional travel.

• Prepare member appeals for insurance company and report information regarding additional insurance coverage to the Third Party Recovery Coordinator.
•  Review medical records for documentation to ensure services meet guidelines.   Document thoroughly, accurately, and timely in the member’s file.  Report all inaccuracies to the appropriate entity.

• Obtain additional documentation from various sources including: labs, hospital records, and out-patient facilities.
• Participate in the education process of the providers, pharmacies, suppliers, health care facilities and members to ensure they have an accurate understanding of CMS guidelines for Medicare/Medicaid.
• Assist the Quality Improvement Coordinator with the annual DMAP Quality Improvement Evaluation.  This includes pamphlet distribution and participation in staff education.

• Develop and maintain office procedures specific for insurance companies.

• Learn and adhere to the Fraud and Abuse Policies and Procedures and report any known cases to the Chief Compliance Officer.
• Assist the medical director and medical management supervisor as requested with research, special projects and other assigned duties.

We offer a competitive salary based on experience and a comprehensive benefits package which includes, Medical, Dental and Vision insurance, Life insurance, Flexible Spending Accounts, Simple IRA with matching (no waiting period), Holidays and PTO. Relocation assistance is available for this position.

This position is located in Roseburg, OR, which is in Southern Oregon. Roseburg is a fabulous community located on the famed Umpqua River, which is one hour from the Cascade Mountains and one hour from the Pacific Ocean. The Umpqua River Valley is surrounded by beautiful evergreen hills and provides a multitude of outdoor activities such as mountain biking, hiking, camping, boating, fishing, kayaking, canoeing, tennis, golf, and much more. Umpqua Valley is also becoming known as a quality wine growing and making region. We boast well over 10 quality wine labels and winemaking is quickly becoming an important industry to this area. This area continues to grow from our new industry and the appeal of the beautiful area. Real estate in Roseburg, OR is still reasonable and many people have been relocating from more expensive areas on the West Coast to take advantage of the real estate opportunities. For more information on Roseburg you can visit www.roseburgareachamber.org.
If you are interested in this opportunity please send your resume to ksandfort@dcipa.com
 

 

• Director of Medical Management and Quality Improvement

Are you a nurse with managed care skills who’s committed to health care for all?

 

Looking for a collegial working environment where you can expand your leadership skills?

 

Want to apply your dedication, expertise, and compassion to an organization that shares your values?

 

Progressive health care organization in Alameda, California has a fulltime, salaried position with excellent benefits for someone with a mission to improve health care access and quality.

 

Company 
The Community Health Center Network has been providing managed care and quality improvement services to a diverse group of non-profit health clinics for more than 10 years.  Member clinics include La Clinica de la Raza, Asian Health Services, LifeLong Medical Care, Native American Health Center, Axis Community Health, Tiburcio Vasquez Health Center, and Tri-City Health Center.

 

Position Summary
The Director of Medical Management and Quality Improvement provides oversight for our medical/utilization management and quality improvement programs.  Working closely with our medical director and nurse case manager, this person has responsibility for HMO contractual requirements, utilization management coordination, and quality improvement studies.

 

Duties and Responsibilities

• Provide oversight for medical management including: representation at health plan meetings and audits, and development and maintenance of medical management plan, policies, procedures, and reports.
• Provide oversight for quality improvement activities including: representation at health plan meetings and audits, and development and maintenance of QI plan, policies, procedures, and reports.
• Supervise Clinical Services Coordinator, Utilization Management Coordinator, Intake Assistant and Nurse Case Manager.
• Manage and coordinate the processing of authorizations, concurrent and out-of-plan reviews, and denials according to standards.
• Work with Clinical Services Coordinator to maintain quality improvement program studies, access audits, and member/provider satisfaction surveys.
• Serve on management team & work at integrating medical and quality management into other MSO departments.
• Respond to all audit deficiencies.
• Chair quarterly clinic managers meetings and communicate current MSO processes.
• Collaborate with Medical Director to develop agendas for the monthly UM Committee and QI Committee.
• Work closely with Case Manager on high risk patients.
• Analyze utilization patterns to support development of disease and case management activities.
• Serve as the quality and medical management representative on the CHCN data team.
• Other duties as assigned.

Qualifications

• RN license desirable; LVN/NP may be considered.
• 3+ years in Medical Management / Quality Improvement in hospital, HMO, or IPA setting.
• 2+ years in health care delivery at hospital, clinic, or physician’s office.

Send your resume to jobs10@chcn-eb.org; or fax: 510-769-2209.

 

 

• Director, Medical Management
  Washington, DC

Scope of Responsibility

Provides leadership and direction of the Medical Management Department, including the programs of Utilization Management, Care Coordination/Case Management, Disease Management, Grievance and Appeals and Quality Improvement.

 

Responsibilities

• Manages a diverse staff of clinical and non-clinical personnel whose primary goal is to manage and promote quality healthcare for the members of the health plan.
• Creates and manages the strategic plan for the department and ensures progress toward corporate goals and vision.
• Creates and manages the budgets of the medical management department, including annual budget submission, monthly variance reporting, and adherence to approved budget.
• Analyzes and monitors workflows and processes to ensure effective overall performance within the department and between other departments within the Plan.
• Mentors management staff to strengthen managerial skills to provide leadership and coaching for mentoring their staff.
• Collaborates with other senior leadership team members to support and implement strategic plans of the organization.
• Provides leadership and direction for the daily operation of the Utilization Management/Authorizations Departments.
• Responsible for designing and administering a program of Care Coordination for all enrollees integrating Case Management and Disease Management Program activities and supported by other departmental policies and procedures.
• Participates in compliance and quality management efforts with a medical management focus to support the organization's accreditation, governmental and regulatory objectives.
• Develops departmental documents including the Utilization Management (UM) Program Description, UM Workplan Evaluation, UM Workplan and Policies and Procedures.
• Communicates, collaborates and assures cooperation with network and community physicians, hospital leaders, and other providers regarding health services and access to quality, cost effective health care services.
• Interacts with and supports other department team members in initiatives that promote overall quality in members' healthcare and health services operational issues.
• Monitors utilization frequency, quality and financial reports, by product line and aggregate, to identify changes in access patterns, trends or overall quality in healthcare of plan membership.
• Monitors trends in UM and recommends changes in UM strategies to improve cost-effective, high-quality utilization.
• Sponsors/leads projects that support strategic organizational initiatives. Participates on teams/committees as appropriate.

Knowledge, Skills and Abilities

• Position requires outstanding oral, written communication skills, problem solving, and organizational and interper- sonal skills.
• Requires leadership and management skills to lead and motivate a large diverse staff of clinical and non-clinical personnel. Also requires self-motivation, the ability to make independent, sound decisions, and to evaluate, plan, and implement change.
• Strong project management skills and the ability to lead interdisciplinary teams.
• Budget and financial planning skills required. Data analysis and interpretation skills, including the ability to understand and manage utilization, financial and operations data also required.
• Registered nurse with current license.
• CPHQ or CCM preferred

Education

• Graduate of accredited school of nursing
• Undergraduate degree in nursing or management required
• Master's degree strongly preferred
• Unrestricted nursing license in the District of Columbia

Work Background and Experience

• Five (5) years clinical nursing experience
• Five (5) years managed care experience required
• Five (5) years of healthcare management experience at a supervisory or managerial level
• Comprehensive knowledge of the care continuum, alternate environments of care, and the business aspects of risk contracting and health plan management
• Working knowledge of government program regulations
• Working knowledge of accreditation standards such as NCQA and URAC

For more information, contact David Mara at 804.527.1905.

 

• Manager Care Management
  Toledo, OH

Brief Description of Duties

• Oversees all day-to-day activities for the Utilization Management department which may include pre-certification review, concurrent review, retrospective review and discharge planning.
• Reviews daily, weekly and monthly production and quality data to identify individual/unit performance strengths and weaknesses.
• Coordinates individual units activities with other care management functions as well as other MMO divisions to ensure optimal performance and cost effectiveness to meet corporate goals and objectives.
• Responsible for the hiring, training, performance evaluation of staff.

Minimum Qualifications or Equivalents

• Bachelor’s degree in a health related industry.
• Registered Nurse with current State of Ohio license.
• Three years clinical nursing experience.
• At least two years experience in management.
• Strong knowledge of all facets of claims/medical procedures, terminology, and payment analysis.
• Thorough knowledge of cost containment activities.
• Analytical skills.
• Strong interpersonal skills.

Preferred Qualifications

Prior experience in managed care specifically in utilization, medical review, or case management areas.

 

For more information, please call David Mara at 804.527.1905.
 

 

• Manager Case Management
  Cleveland, OH

Brief Description of Duties
The manager will oversee the functions of the case management department. The manager ensures compliance with nationally recognized accreditation and governmental standards, as well as, compliance with case management standards. In addition, will oversee committees for case management to ensure that policies and procedures are developed and are in alignment with the standards and regulatory bodies and the core components of the case management process are followed; that quality assurance is conducted regularly to ensure compliance to policies and procedures and standards’ and to ensure that case managers are educated in accreditation standards, the case management process, concepts and standards.

• The Case Management manager will oversee staff to ensure that staff practices case management within the scope of their licensure (based on the standards of the discipline).
• Monitors and evaluates the effectiveness of programs and procedures and recommends/implements changes as indicated.
• Monitors case management committee structure activity (including: Policy and Procedure, Quality Assurance, Program Content and Resource and Education committees) to ensure departmental consistency.
• Responsible for revising, developing, and implementing cost savings methodologies.
• Develop process for better integration between case management, physician advisors and other internal departments.
• Responsible for the hiring and performance of case management staff.

Minimum Qualifications or Equivalents

• Bachelor’s degree in a health related field and licensure as a health professional where available and/or Registered Nurse, current in the State of Ohio with 3-5 years of clinical nursing experience.
• Certification as a Case Manager.
• Previous management experience.
• Excellent interpersonal and written communication skills to. collaborate/interact effectively and confidentially with internal and external contacts.
• Ability to travel to various locations with access to own transportation for business use.

For more information please contact David Mara at 804.527.1905.
 

 

• Manager, Provider Relations and Contracting
  Austin, TX; Ft. Lauderdale, Orlando and Tampa, FL

Description
This behaviorial health company is a multi-line managed care organization that provides Medicaid-related programs to organizations and individuals through government subsidized programs. We have an excellent opportunity for a Manager of Provider Relations and Contracting. This position will implement development activities for the recruitment, contracting and retention of providers. Negotiate contracts and develop strategies and methodologies for specific network development initiatives.

 

Position Responsibilities Include:

• Monitor business processes related to network development to determine their efficiency and protective value, and   assure integrity of records, information and systems in compliance with Company policies/standards and govern-  ment regulations.
• Develop tactical plans to align network strategies and technologies with future needs. Effectively integrate new   networking strategies and technologies.
• Oversee marketing efforts in each market.
• Prepare and analyze reports and records on functional area and on organizational activities, recommend improve-  ments for upper management. Monitor and report on achievement of committed action plans to appropriate upper management.
• Monitor operational and financial performance of agreements using results to guide future negotiations.
• Meet individually with providers to develop long-term relationships and resolve operational issues.
• Review redline contract language and provide accept/decline recommendations to management.
• Prepare and analyze information to evaluate the need for additional providers.
• Assist in maintenance of ongoing state governmental and community relationships.

Qualifications

• A Bachelor’s degree
• 3-5 years experience with project management and supervisory/lead experience.
• Experience in a healthcare or insurance environment, Medicaid preferred.

For additional information, please contact David Mara at 804.527.1905.
 

 

• Director, Seattle Synergy Operations
  Seattle, WA

Job Summary

The Director, Seattle Synergy Operations directs and oversees the operations for the Seattle Call Center. The Director of Seattle Synergy Operations is a full time position that provides day-to-day professional, technical and managerial support to the Seattle Synergy clinical and non-clinical staff to ensure compliance with program policies and procedures, industry standards and regulatory requirements. This individual will be responsible for the integration and coordination of Care Coaching Program services for clients serviced out of the Seattle Call Center. The Director works closely with the technical support staff, managerial staff, and other clinical departments in Tampa and Seattle to ensure quality service delivery. This individual will serve as a liaison between care coaching staff, providers, patients and health plans/clients.

 

Minimum Qualifications

 

Education

Minimum of a bachelor’s degree in a health care field. Masters preferred.

 

Licensure

Active, unrestricted RN or other health care licensure required.

 

Experience

Minimum of 5 years of demonstrated Call center and/or Managed Care leadership experience at a manager/director level required, with specific experience in Disease Management or Case Management preferred.

 

Knowledge

• Demonstrated in-depth knowledge of call center management.
• Demonstrated in-depth knowledge of Disease Management and Case Management principles.
• Excellent communication skills, both verbal and written.
• Ability to direct and coordinate programs, projects, resources, and staff across multiple company departments and locations.
• Ability to analyze telephone statistics and other program data to set and monitor goals; implement corrective strategies to improve effectiveness and efficiency; and identify opportunities for program improvements.
• Working knowledge of government sponsored programs (Medicare, Medicaid, etc) and regulations surrounding these programs.
• Demonstrated leadership abilities in a clinical operations environment.
• Ability to communicate effectively with a wide range of individuals, both internal and external.
• Must be able to work independently, while coordinating operational processes with the Tampa operation.
• Excellent computer skills, including use of Microsoft Office Suite and other office productivity software, and disease management applications.
• In-depth knowledge of managed care operations, including benefit design and UM/CM techniques.

Accountabilities

 

Job Performance/Responsibilities

 

General Duties

• Management of the Seattle Synergy operations staff and the Seattle call center.
• Provides the day-to-day professional and technical support to the Synergy staff to ensure efficient operation of the department; including compliance with policies and procedures, contractual obligations and regulatory requirements.
• Assures that all regulatory and accreditation standards are implemented and met.
• Assures that Policies & Procedures, Operational Guidelines, and process workflows are implemented and adhered to by staff.
• Analyzes Seattle call center data to ensure effectiveness, quality, productivity, and profitability standards are met.
• Assures staffing is optimized to effectively and efficiently deliver Synergy services to members and clients.
• Develops and implements work flows and policies and procedures that accurately document the Synergy operation.
• Provides input into existing reports and provides suggestions for enhancement.
• Manages the budget associated with the Seattle operation.
• Interviews and hires staff and supervisors for the Synergy Seattle operation.
• Participates with the sales team in delivering prospective client presentations about the Synergy program.
• Actively interacts and collaborates with clients regarding the Synergy program; participates in client presentations and account meetings.
• Assists in the licensing and accreditation process for all programs.
• Assists the Vice-President in plans for growth.
• Provides input and direction to Information Services on systems issues and enhancements.
• Offers input and assistance with development of education and training programs.
• Assures delivery expectations of client contracts are being met.
• Provides required reports and special projects as needed.
• Provides input to the Vice President and Executive Vice President regarding program enhancements and operational improvements.
• Assists in the annual review of the Program Description; provides input into the annual program evaluation and the program work plan.

Please direct all inquires to Dave Mara at 804.527.1905 or email him at dmara@namcp.org
 

 

• Sr. Vice President of Quality Improvement, Training and Regulatory Affairs
  Tampa, FL and Seattle, WA

Job Summary

The Senior Vice President of Quality Improvement, Training and Regulatory Affairs is responsible for the development and implementation of corporate Quality Improvement initiatives, Education and Training programs, Corporate Compliance  and directives as well as the oversight of accreditation standards .

 

Minimum Qualifications 

 

Education

RN degree level health care clinician.  Additional certification in specialty fields or other advanced certification preferred. 

 

Experience

8-10 years experience in Quality Improvement. Five years Director level management experience specifically in Quality Improvement/Management. Working knowledge of NCQA and URAC accreditation standards and direct experience with and responsibility for NCQA and URAC surveys. Experience in both the health plan environment as well as in a health plan vendor organization environment. 
 
Knowledge/Skills

• Sound computer skills and experience with Microsoft Office Suites including the development of spreadsheets.
• Current, broad-based expertise in managed care, quality improvement. processes, URAC, NCQA, and state and federal guidelines in healthcare.
• Sound leadership skills and interactions with physician (s), operational and clinical staff, peers, Senior Management and business leaders.
• Must be able to multi-task and work independently.
• Sound critical thinking, communication skills.
• Business administration skills.
• Sound problem solving and decision making skills.
• Ability to do presentations inside and outside the organization.
• Statistical and analytical skills.

Accountabilities

• Monitors the structure, functions, and coordinate the Quality Improvement Committee.
• Oversight of the QI staff and department through supervision of the Vice President of Quality Improvement.
• Monitors compliance with all accreditation.
• Implementation of organizational wide quality improvement indicators and processes.
• Evaluates the effectiveness of Quality Improvement program.
• Oversight of and provides direction to corporate Training and Education initiatives.
• Oversight of Corporate Compliance initiatives and program.
• Monitors all accreditation standards and ensures they are met and implemented throughout the organization.
• Assists Operations in the clinical process and the clinical integrity of clinical programs.
• Assists and actively participates in Sales & Marketing, Client Services, and New Product Development.
• Identify changes in healthcare accreditation environment and communicate those changes to appropriate individuals/departments.
• Other duties as requested and/or assigned by the Chief Medical Officer.

Customer Services-Internal

• Supports a positive working environment.
• Identifies and resolves potential personnel/peer problems and issues proactively.
• Monitors and reports to QI Committee as well as the Executive Management Team any issues or concerns related to QI indicators.
• Maintains a courteous and professional attitude when working with all staff members and the management team; and other departments.

Customer Service-External

• Maintain a professional attitude/image when communicating with Health  Integrated visitors, customers, and/or clients.
• Collaborates with Health Integrated clients/customers/audit/surveyors in a professional manner.
• Report all quality improvement data/issues to Health Integrated’s clients in a timely manner.
• Supports/maintains positive relations with Health Integrated clients/customers.

Please direct all inquires to Dave Mara at 804.527.1905 or email him at dmara@namcp.org
 

 

• Director, Accreditation and Delegation Oversight
  Baltimore, MD

Position Summary

The Director of Accreditation and Delegation Oversight is responsible for creating a strategy that will promote success in achieving the organization’s goals for accreditation in designated markets. This position provides project management of accreditation and external quality review activities as well as develops and maintains a delegation oversight program and ensures oversight occurs in accordance with CMS and NCQA standards. Excellent communication skills required, both written and oral, to internal and external stakeholders. The ability to establish and maintain effective working relationships with State, CMS and accreditation organizations is essential. Responsibilities also include compiling and completing reports for quality improvement and provider advisory committees.

 

Essential Duties and Responsibilities

• Complete and maintain a crosswalk between CMS, NCQA and state regulations related to quality.
• Standardize related processes, policies and procedures and standard operating procedures.
• Refine Delegation Oversight Program and tools.
• Ensure that all delegated activities are reviewed on a regular basis according to applicable NCQA, CMS and state standards and plans of correction are tracked and outstanding issues addressed in a timely manner.
• Develop policies and procedures and standard operating procedures as needed.
• Collaborate with departments to address gaps and open tasks.
• Identify training needs of staff and resources related to NCQA and other quality standards. Facilitate training in these areas.
• Coach staff on standards and documentation to demonstrate compliance.
• Create status reports and present to Quality Improvement Committee and other meetings.
• Create reports for state Medicaid programs, CMS, EQRO and NCQA organizations
• Assist and support VP, Quality as required.

Qualifications

• Knowledge of NCQA and government standards and participation in an NCQA review is required.
• Experience in quality improvement in a managed care setting required.
• Experience as a leader in complex or system-wide project management required.
• Professional attitude and team player, with ability to work independently.
• Experience coaching and mentoring staff.
• Excellent phone/communication skills.
• Ability to comprehend technical documents.
• Multiple task oriented.
• Flexible with the ability to shift priorities on short notice.

Education and/or Experience

• Bachelor’s Degree, Health Care preferred
• Three years experience leading accreditation activities
• Familiarity with project management process and tools

For additional information, please contact David Mara at 804.527.1905 or email your resume to dmara@namcp.org
 

 

• Associate Vice President, Health Care Management Services
  Austin, Texas

Job Summary

The Associate Vice President Health Care Management Services manages the utilization/care management process ensuring the delivery of essential services that effectively address the total healthcare needs of the health plan’s members.

 

Primary Responsibilities

• Implements and manages health care management, utilization, cost, and quality objectives in accordance with the goals of the health plan’s mission, vision and values, the needs of the health plans, federal and state regulatory requirements and NCQA standards.
• Collaborates with the peers to ensure a seamless interface between HCMS and Medical Management.
• Identifies opportunities to improve the customer service and quality outcomes for our members.
• Collaborates with peers to initiate innovative health care pilots to improve the overall HCMS/medical management program.
• Interfaces with other departments to ensure the complete integration of behavioral health and physical health.
• Overseas the development of medical management policies, procedures, and guidelines.
• Ensures implementation and continued compliance by providing updates on specific medical management standards to Directors and staff.
• Assists in developing clinical management guidelines including: Conducting literature search to identify "evidenced- based" management. Identifying changes in practice which may require updating of guidelines. Developing DRAFT guidelines as directed. Identifying national providers experienced in treating patients. Coordinating physician advisory groups.
• Ensures that delegated medical management activities are contracted, reviewed and reported according to estab- lished criteria.
• Evaluates programs quarterly.
• Supports and participates in quality initiatives and activities including clinical indicators reporting, focus studies and HEDIS reporting.
• Ensures compliance with state reporting on utilization management activities for accuracy. • May develop the annual operating and capital budgets to sufficiently meet departmental needs.

Education and Experience

Required

• Bachelors Degree in a health care field

Preferred

• Masters Degree in a health care field
• MSN, MPH, MPA, or MSW or related or MBA with Health Care concentration

Years and Type of Experience

Required

• Must have three years post Masters clinical experience.
• Must have at least five years of current experience in utilization management in a managed care setting.
• Must have 3 years of management experience.

Knowledge and Technical Skills

Required

• Industry and clinical knowledge - Possesses a comprehensive knowledge of managed care, best practices, and issues related to coordinating behavioral and physical health.
• Leadership - Sets a clear direction for health care. Balances marketplace requirements with the objectives of the health plan's health program. Able to manage indirect reporting relationships.
• Management of resources - Manages human resources to optimal performance. Efficiently manages projects to a timely completion. Identifies gaps and proposes solutions. Able to develop and manage budgets.
• Communication skills - Strong verbal and written communication skills. Able to negotiate with a variety of stakehold- ers. Capable of networking with internal resources as well as external partners and constituents.
• Computer skills - Possesses a working knowledge of Microsoft Office and the Internet. Interested in developing higher-level computer skills.Certifications or Licensure

Preferred

• RN
• LCSW, LPC
• Certified Case Manager

For more information, please contact David Mara at 804.527.1905.
 

 

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