- Director Health Care Management Services - Disease
Management
Virginia Beach, VA
Job Summary
The Director, Health Care Management Services is responsible for the
development, implementation and coordination of a comprehensive
health care program that will assist Health Care Management
Services, Medical Management, and/or Health Plans, resulting in
improved health outcomes for members.
Primary Responsibilities
- Assists in development and implementation of clinical programs
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.
- Serves as a clinical leader to HCMS/Medical Management
associates.
- Manages and evaluates team’s performance and ensures adherence
to department’s standards.
- Provides departments with updates as needed to ensure continued
compliance with specific medical management standards.
- Assists in the development of medical management policy,
procedures and guidelines that relate to specific programs.
- Assists in evaluating and implementing contracts in coordination
with Network Development as needed to implement specific programs.
- Assists Member Services and Provider Inquiry Department with
timely response to issues including complaint resolution.
- 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
within these areas.
- Coordinating physician advisory groups.
- Assists in managing the information requirements of HCMS/Medical
Management programs.
- Acquires data and evaluates necessary medical, mental health and
substance abuse services for cost containment.
- Identification and implementation of HCMS/Medical Management
"best practices."
- 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 assist in developing the annual operating and capital
budgets to sufficiently meet departmental needs.
Education
Required: Bachelors Degree, or equivalent work experience
Preferred: MSN, MPH, MPA, or MSW or related or MBA with Health Care
Concentration
Required
- Must have five years management experience.
- Must have at least five years of current experience in
utilization management in a managed care setting.
Knowledge and Technical Skills
Required:
- Demonstrated medical management experience in health care.
- Knowledge of Utilization Management targets.
- Self-directed with strong organizational skills.
- Excellent verbal and written communication skills.
- Ability to foster inter and intradepartmental communication and
team building.
- Strong analytical capabilities.
- Attention to detail.
- Mastery of computer software.
- Statistical reporting experience preferred.
- Multi-task oriented with ability to follow-up on numerous
complex problems.
- Strong customer focus.
Certifications or Licensure
Required: RN or LCSW , LPC
Preferred: Certified Case Manager
For more information, please call 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.
Make it yours. At Kaiser Permanente, we
realize that it takes more than expert medical care to be the
nation’s leading nonprofit integrated health plan. It takes advanced
technologies, state-of-the-art facilities, and the people to support
them. Come impact your future, and the future of care. Join us in
Oakland, California.
State Programs Clinical
Consultant
This individual will act as a clinical
consultant and content expert for complex functional areas
comprising the continuum of clinical services provided under Kaiser
Permanente’s Medi-Cal and state program agreements. Specific tasks
include coordinating health plan audits; providing medical and state
programs expertise to regional, local, and statewide operations to
ensure compliance; and answering questions regarding utilization
review, quality review, links and carved out services, appeals and
grievances, and case management. In this position, you will also
work with Kaiser Permanente departments and senior leadership at
divisional, regional, and local levels as consultant on Department
of Managed Health Care compliance issues on existing and planned
operations. In addition, you will participate in the ongoing
development and implementation of education programs about Medi-Cal
and state program clinical-related business and regulatory
requirements.
A bachelor's degree in business
administration, health care administration, public health
administration, or other related field is required; a master’s
degree is strongly preferred. A current California Registered Nurse
license, five years of clinical RN experience, and five years’
experience in interpreting and managing Medi-Cal, Medicare, Title
22, and other government program requirements are also required. You
must also have the ability to manage multiple projects and use
excellent analytical skills on highly complex, politically sensitive
projects by identifying key business issues, and develop action
plans recognizing differing and competing multidisciplinary
perspectives. In addition, strong collaboration and communication
skills working with key clients and senior leadership are essential.
Health care operations, managed care, health care insurance, health
care compliance, and consulting experience preferred. Knowledge of
Kaiser Permanente and state program regulations, demonstrated
contract negotiation experience, and working knowledge of regulatory
state program environment highly preferred.
We offer a highly competitive salary and
an exceptional benefits package. For immediate consideration, please
e-mail your resume to
jermaine.b.jenkins@kp.org.
Please reference Source Code SPCC031808CAHQ when responding. Please
visit jobs.kp.org for complete qualifications and job submission
details, referencing job number RE.0800240. Principals only. Kaiser
Permanente is an EOE/AA employer.
This position supports Kaiser
Permanente’s code of conduct and compliance by adhering to all laws
and regulations, accreditation and licensure requirements, and
internal policies and procedures.
jobs.kp.org
KAISER PERMANENTE
- 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 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 implementation 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 additional information,
please contact David Mara at 804.527.1905.
- Senior Clinical Director
Aetna
High Point, NC
Aetna, a leading
provider of healthcare and related group benefits is seeking a
Senior Clinical Director to oversee their office in
High Point, NC. This senior nursing executive will have an
opportunity to hire a staff of high performing professionals to
address the member’s needs across the continuum of care.
- Will develop co-management processes
and workflows in conjunction with Disease Management, Behavioral
Health and other Aetna service areas.
- Creates direction and communicates a
business plan focusing on key priorities.
- Responsible for implementing Aetna’s
medical management policies and procedures.
- Accountable for meeting the
financial, operational and quality objectives of the unit.
Requirements
- Bachelor’s prepared seasoned nurse
executive, forward-thinking, self assured and outcome-directed
professional with the unequivocal ability to lead.
- 10 years of clinical experience with
several years overseeing a team of professionals in a managed care
setting is essential.
If you might be interested in learning
more about this position I would welcome an opportunity to speak
with you.
- Outreach Coordinator
Springfield, MA and Boston MA
Job Summary
Serves as the liaison and advocate for
members in support of the Synergy Personal Health Management
Program. Provides education, assessment and outreach to high risk
and/or non-compliant members with chronic diseases to encourage
participation in the Synergy program. Serves as the direct
interface with network practitioners, providing outreach, education,
and clinical guidance on program strategies. Works closely with
Client clinical departments to ensure collaboration between the
Health Plan and the Synergy program staff.
Minimum Qualifications
Education
Bachelor’s Degree in a health related field. Master’s Degree
preferred, such as MSW, MPH, MHA, MSN, etc. Licensure as a health
professional desirable.
Experience
Minimum of three years experience in a health care delivery
environment, managed care plan, or Disease Management provider.
Experience as a consumer or family advocate, either in volunteer or
paid settings, with knowledge of Medicaid and Medicare
regulations/standards preferred.
Knowledge/Skills
- Knowledge of Medicaid and/or
Medicare health care delivery system.
- Knowledge of local and community
resources and social services.
- Knowledge of disease management
processes.
- Case Management skills.
- Independent, highly organized team
player.
- Able to handle multiple tasks
simultaneously.
- Must be able to access, research and
extract information from printed and online resources.
- Knowledgeable in case management
software systems.
- Excellent verbal and written
communication and presentation skills.
Accountabilities
Job Performance/Responsibilities
- Assists call center Care Coach staff
in locating and/or engaging high risk and/or non-compliant members
with chronic diseases.
- Builds and maintains library of
community and social service resources to support Care Coach
interventions.
- Works closely with customers to
assist in training on the Synergy program, consumer rights and
responsibilities, self-help, recovery, and advocacy.
- Acts as a liaison between the
customer’s UM/CM department(s) and the Synergy program.
- Maintains a strong working knowledge
of local practitioner networks as well as local and state resources
for health care treatment.
- Facilitates problem resolution
related to specific patient issues, working effectively with Care
Coaches, providers and provider office staff.
- Facilitates coordination and
collaboration with network practitioners through ongoing
communication and outreach activities.
- Maintains open communications with
customers in the coordination of provider activities as necessary
and appropriate.
- Conducts ongoing education and
re-orientation for providers and their staff on Synergy program
strategies.
- Attends all consumer and key
advocacy meetings and maintains memberships within these
organizations.
- Conducts educational and outreach
training activities for members with chronic diseases in conjunction
with customer health fair and training programs.
- Conducts formal investigations on
consumer complaints and ensures the issues are followed through to
resolution.
Please direct all inquires to
Dave Mara at 804.527.1905 or email him at
dmara@namcp.org
- 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
- Manager, Clinical Training
Hunt Valley, MD
Summary
The Manager of Clinical Training will
lead a multi-discipline training and development function for
clinical and clinical support staff. The Manager of Training will
design and implement clinical training programs for employees across
the health plan's business units who work in facility-based settings
as well as at home throughout the country. This position is
primarily responsible for ensuring that clinical and clinical
support staff have the knowledge and skills required to deliver the
health plan's clinical programs in accordance with performance
standards. Periodic travel to worksites in Maryland, Ohio, and
Georgia is required.
Qualifications
- Bachelor's Degree in Nursing or
other Health Care Professions, Business, Healthcare Administration,
Education or related field required, Masters Degree strongly
preferred.
- Minimum eight years of experience as
a Trainer.
- Minimum three years working in a
healthcare setting with clinical training programs.
- Minimum two years leading a team or
supervising staff.
Responsibilities
- Consult with management team to
identify current and future training needs and develop a strategy to
build the knowledge and skill sets needed to achieve performance
standards.
- Lead the development of training
modules, resources and materials, and implement new approaches that
maximize the use of technology in the delivery of quality training
programs (i.e. E-Learning, self-paced training, interactive
training).
- Design, develop and deliver
effective learning outcomes.
- Assess clinical training program to
measure skill acquisition and learning results for effectiveness and
return on investment.
- Develops and coaches training teams
in response to business unit performance improvement initiatives
that support the Enterprise strategy. Designs, consults and
coordinates resources with clients and team members on the
development and delivery of training needs. Participates in the
integration of training as part of attaining performance excellence
and accomplishing strategic goals. Tracks training development and
revisions with recommendations for quality assurance.
- Manages specific tasks in
implementing a systematic approach to quality training with
consultative roles in the development and validation of training
programs that fit the strategic direction of assigned
product/functional areas and the distribution systems served by the
area.
- Coordinates the performance of the
team, developing project specifications, budgets, work plans,
assignments and time lines in accordance with performance
management, development, support and operational needs.
- Assumes responsibility for
long-range planning to ensure appropriate instructional technologies
are in place to maximize training resources.
- Ensures team expectations (team
member roles/contributions) are clearly communicated. Monitors,
measures and rewards individual and team contributions.
- Serves as liaison with outside
consultants and vendors who may be retained to fulfill specific
training objectives.
- Manages the hiring, supervising,
training, and promoting of candidates regardless of race, color,
age, sex, religion, national origin or disability in support of
Nationwide's Affirmative Action Program.
Knowledge, Skills and Abilities
- Knowledge of Adult learning
principals
- Extensive knowledge of and ability
to train on Educational Psychology - Behavior Modification,
Behavioral Change, Self-Efficacy, etc.
- Ability to create CBT or the
equivalent.
- Ability to prioritize and manage
concurrent projects, demonstrate initiative and work independently
with minimal supervision.
- Must possess effective presentation
and educational delivery skills.
- Ability and willingness to adapt to
changing priorities and aggressive project deadlines.
- Ability to utilize technology to
maximize training effectiveness.
- Effective interpersonal,
communication and presentation skills and styles.
- Ability to communicate and operate
at all levels of the organization.
- Excellent organization and project
management skills.
For additional information,
please contact David Mara at 804.527.1905 or email your resume
to dmara@namcp.org
- Director, Clinical Accounts
Shelton, CT
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
The Director, Clinical Accounts is
responsible for region activities related to process improvement and
project implementation of the clinical account management program. A
strong focus is placed on identified groups, including planning,
development, implementation, and monitoring of population programs
for the identified population.
Essential Duties and
Responsibilities
- Develops and implements short
term/long term Health Management programs geared towards specific
populations, working with Medical Policy and Analytics, Medical
Directors, Sr. Account Managers, clinical account managers, group
representatives, and others. Works with vendors, providers and Care
Managers in program implementation and monitoring of health
outcomes.
- Participates in the planning,
implementation and assessment of corporate programs designed to
proactively identify members who are at risk and in need of care
management services.
- Implements processes to insure
members are enrolled in the appropriate Disease Management program.
- Uses utilization data as well as
outcome data to plan and measure a program’s effectiveness.
- Monitors the effectiveness of
programs on health outcomes in collaboration with Disease Management
and Care Management. Assesses and participates in the evaluation and
revision of Care Management programs to optimize health outcomes.
- Works in collaboration with the VP,
Medical Policy and Analytics to identify areas of opportunity and/or
provider education.
- Maintains group relationships as
needed on a daily and aggregate basis to assure the care given to
our members is appropriate and compliant with Health Net policy and
governmental regulatory requirements.
- Communicates with providers, members
and community resources as necessary to support the planning,
implementation and evaluation of care management programs.
- Participates in corporate and state
regulatory activities. Performs audit activities as required,
participates in establishment of corrective action as necessary.
- Supervises the Clinical Account
Managers.
Requirements
Education
Bachelor’s Degree
Certification/License
Current RN Professional Licensure
Experience
- Experience in Disease Management or
Case Management program development and implementation preferred.
- Five years of clinical experience,
at least two years of supervisory experience, preferably with HMO
experience in a medical management capacity is preferred.
- Project management experience highly
desirable.
- Demonstrated progressive patient
management expertise is required
Knowledge, Skills & Abilities
- Must have a “can-do” attitude and a
proven successful track record in the assessment, planning,
implementation, coordination, monitoring and evaluation of the
management of member’s care.
- Proficiency with windows based
applications is required.
- Must be goal oriented and able to
participate in a team environment with other motivated associates to
move towards a common goal.
- Must have the ability to work in an
environment of continuous process improvement.
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, visit:
WWW.CAREERSATHEALTHNET.COM, locate this position by Job Number
08000377, scroll down, click ob job title and apply online.
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.
- 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.
- Director, Acccreditation and Delegation Oversight
Baltimore, MD
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 Experience
-
Bachelor’s Degree, Health Care preferred.
-
3 years experience leading accreditation activities.
-
Familiarity with project management process and tools.
Please direct all inquiries to Dave Mara at 804.527.1905 or
email him at
dmara@namcp.org
- Director, Medical Management
Magellan Health Services
Phoenix, AZ
This Director position maintains accountability for all Clinical
Review functions and efficiency of clinical review processes.
Maintains and supports UM compliance, including customer compliance,
due diligence, as well as URAC, NCQA and other applicable standards.
Provides support and communication for external clients in areas of
medical management and clinical review.
Responsibilities/Duties
- Works closely with Vice President of Clinical Operations to
provide NCQA and URAC guidance and oversight for the clinical review
process.
- Maintains oversight for the success and completeness of the
Quality Management and Utilization Management Programs for Clinical
Operations.
- Continuously provides feedback and suggestions for improvement
of Informa.
- Directs, coordinates and evaluates efficiency and productivity
of the initial clinical reviewer functions, and appeal process.
- Responsible for resolution and communication of medical
management issues, client maintenance, concerns and corrective
action plan activities and reporting.
- Acts on an ad hoc basis as Clinical Implementation Specialist
working with the Network Operations, Provider Services Group, and
Client Integration Team, supporting medical management process.
- Member of Utilization Management Committee.
Knowledge, Skills & Abilities
- Thorough understanding of health care financing and payment
systems.
- Excellent quantitative and analytical skills.
- Excellent verbal, written, and communication skills.
- Customer oriented with excellent interpersonal skills and strong
commitment to quality patient care.
Education & Experience
- Current Arizona Registered Nurse with active license.
- Baccalaureate degree required or equivalent experience.
- Masters degree preferred.
- A minimum of ten (10) years experience in healthcare management.
- At least five (5) years experience in a managed care
environment.
- At least five (5) years experience in a management level in
Utilization and Quality Management.
Please conact Terri Holub, Sr. Sourcing & Research Recruiter at
Magellan Health Services, Inc.
(888) 899-7803 ex. 65162
(916) 852-2643 fax
- Manager, Quality Outcomes
Baltimore, MD
Position Summary
The Manager of Quality Outcomes coordinates the
operational components of the Quality Improvement process on a daily
basis, meeting state and federal regulatory requirements and the
expectations of providers and members.
Essential Duties and Responsibilities
- Educates staff on the principles of quality
improvement and acts as a staff resource for quality improvement
questions.
- Investigates quality of care issues for all
regions, maintain a database, produce quarterly reports to
credentialing, the QIC and Board of Directors.
- Oversees the QAPI projects to improve
services to members.
- Participates in NQIP HEDIS data collection
and monthly provider specific reports.
- Oversees the member (CAHPS) and provider
satisfaction surveys, analyzes results and reports to committees.
- Revises and develops policies and procedures
and standard operating procedures related to quality as needed.
- Sets agenda and coordinates QIC meetings.
- Researches and develops preventive health and
other clinical guidelines with the Senior Medical Director.
- Coordinates the development of the Corporate
QI Work Plan and Annual Corporate QI Evaluation with all department
heads.
- Oversees risk management/quality of care
issues tracking and analysis
- Maintains quality improvement issues
documentation and tracking reports.
- Assists other departments in monitoring
delegated functions
- Monitors quality indicators and data analysis
and reports results to committees.
- Monitors and supports the complaints and
grievance analysis.
- Conducts audits on inter-rater reliability.
- Supports Member Services and Provider Network
with member and provider education materials.
- Other duties as required.
Minimum Qualifications
- Bachelor’s Degree in related field
- A minimum of 5 years of clinical experience
in health care
- A minimum of 3 years of supervisory
experience; prior QI experience in a managed care setting preferred.
- At least 3 years recent experience
participating in a leadership role in NCQA accreditation activities.
Certification/Licensure
Registered Nurse (RN) with current license in the
State.
Knowledge, Skills and Abilities
- Ability to adapt and respond to complex, fast
paced, rapid growth/results oriented environment.
- Ability to simultaneously lead and manage
multiple high priority projects and responsibilities.
- Ability to analyze and evaluate data and
problems, develop alternative solutions, and identify trends and
patterns.
- Excellent communication and presentation
skills and the ability to interact with all levels of management, as
well as key state and federal regulatory agencies.
- Ability to positively interact with other
clinicians, senior management, patients and their families, and all
levels of medical and non-medical professionals.
Confidentiality
This position is exposed to patient medical
record information that revealed if inappropriately would be against
company policy, professional ethics and integrity.
Physical Demands/Work Environment
Must be able to work long hours to meet critical
deadlines.
For a more detailed job description or
additional information, please contact David Mara at 804.527.1905 or
email your resume to
dmara@namcp.org
- Director of Utilization,
Case and Disease Management
Nashville, TN
Primary Function
Responsible for development and operational oversight and
day-to-day management of all actrivities associated with the Chronic
Care Improvement Program (case and disease management), inpatient/UM
management (onsite inpatient) and Social Services.
Responsibilities
Serves as point person for Health Services for all CCIP
Programs.
Oversees Health Risk Assessment, CM, DM, SS and Life Enhancement
program and staff.
Coordinates and oversees all Disease Management and Intensive CM.
Develops disease management programs to ensure compliance with all
regulatory agencies, e.g.: HIPAA, CMS, URAC, NCQA, DOI/DOL etc.
Implements and maintains all CCIP management reports.
Evaluates and trends data with a focus on strategic planning.
Works with all plan Depts. in promoting CCIP management programs.
Assists with development of new systems related to areas of
responsibility.
Oversees and develops new programs.
Performs other duties as assigned.
Supervisory Responsibilities
Direct management responsibilities for DM, CM, IP, SS and
LEP.
Job Related Skills
Is a registered nurse in TN with extensive background in
leadership.
Has strategic planning and program development skills.
Is able to communicate information accurately and timely.
Has the ability to articulate information at all levels of
understanding.
Has strong healthcare analytical/problem solving skills.
Has the ability to analyze data and identify trends and
opportunities for improvement.
Has the ability to handle multiple tasks, set priorities and develop
action items.
Is detail oriented.
Is skilled in the diplomatic, educational approach along with
team-building skills.
Experience
RN with five plus years of experiendce in managed care or
healthcare .
Experience or in-depth knowledge with a proven record of disease
management programs including outcomes programs and their
implementation.
Minimum of 5 years experience in management.
Experience and knowledge of regulatory agency requirements.
Please direct all inquiries to Dave Mara at 804.527.1905 or
email him at
dmara@namcp.org
- Concurrent Review RN - Join an industry leader
AmeriChoice, a UnitedHealth Group company, is a recognized leader
and innovator in providing managed health care solutions to its
membership, which includes Medicaid, Medicare and SCHIP recipients.
With over a decade of growth and success, we are poised for
continued expansion of our services in this dynamic marketplace. Our
commitment to this specialized market makes a genuine difference in
the lives of our 1.4 million members. Join us, do rewarding work,
and build a great career.
Are you looking for a change from direct patient care but still want
to use your clinical knowledge to help patients receive excellent
medical care? If so, this could be the perfect position for you!
Corporate growth has created a need for us to hire a new Concurrent
Review Nurse to address utilization management in the Arizona
market. The chosen candidate would work with patients and medical
providers to determine the appropriateness of various types of
medical care. After the candidate has successfully and continually
met performance expectations, he/she may have the opportunity to
work for home.
Key responsibilities include:
- Using Milliman and Robertson (M&R) criteria to evaluate
appropriateness of care
- Performing on-site and telephonic concurrent reviews
- Maintaining ongoing contact with physicians to obtain accurate
patient data and clarify diagnoses
- Communicating care decisions to physicians and case managers
- Helping to develop the Concurrent Review Orientation Program
Only RNs with current and valid licensure in Arizona and clinical
experience will be considered for this position. A background in
hospital-based utilization management or home care concurrent review
is preferred; field-based work is a plus. Basic computer proficiency
is also necessary. If you meet these criteria, and you are an
independent thinker who also works well with other professionals,
consider applying for this promising position.
UnitedHealth Group offers a full range of comprehensive benefits,
including medical, dental and vision, as well as a matching 401k and
an employee stock purchase plan.
Diversity creates a healthier atmosphere: equal opportunity employer
M/F/D/V.
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