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Position Purpose: Creates clinical programs to meet the needs of members in Care Management. Works closely with Medical Informatics team to identify trends that need to be addressed with program management. Monitors the program work plan to assure attainment of Medical Management annual goals. Responsible for Care Management clinical inter-rater reliability and monitoring important aspects of care. Directs the work of subordinates in dissimilar functions.
· Effectively manages the activities of staff providing leadership and guidance.
· Interviews, recommends for hire, and evaluates staff, and counsels and confronts unsatisfactory performance promptly and fairly and administers corrective action.
· Identifies department goals and objectives, develops and communicates action plans through regular staff meetings and other communications, uses team approach to problem solve and sets clear expectations.
· Identifies training needs and develops and participates in staff training. Provides a challenging and supportive environment and delegates appropriately. Seeks additional training opportunities through outside sources.
· Analyzes work plans developed by subordinate managers and monitors the status of their work in relation to the overall schedule requirements.
· Develops monitoring systems and measurements and exhibits a customer service philosophy.
· Manages statistical and qualitative information concerning patient outcomes and physician/hospital practice patterns in accordance with health plans' utilization standards.
· Intervenes with hospital or physician contractors to examine cases to ensure methods for meeting these utilization standards while maintaining precedent for quality of case standards.
· Determines and enforces - through functional groups - medical management requirements in accordance with real company needs, based on current regulations and state-of-the art product development.
· Organizes and promotes medical management functions.
· Evaluates and develops improved techniques for the control of quality and reliability.
· Plans and develops improved techniques for the control of health care costs.
· Plans, on a quarterly or longer basis, the overall use of resources.
· Provides information and advice to higher level management related to medical management.
Education/Experience: Bachelor's degree in Nursing or equivalent required; Master's degree in Health Services Administration or equivalent desired. Five years clinical experience in an acute care setting. Four years experience in quality management/improvement in a health care setting. Two years work experience in a managed care environment. Five years management experience in a health care setting. Three years medical management experience in an HMO setting desired
License/Certification: Must have and maintain current valid and unrestricted Registered Nursing (RN) license. Valid state driver's license
Government Security/Clearance/Citizenship Requirements: Requires US citizenship and current security clearance
Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.
More Information About the Job
Is Relocation Available?
Is there a bonus structure?
20% or higher
Are you open to sponsorship?
This position is:
Is there a possibility to work remote?
Is there equity?
Are there flexible work hours?
Does this position have direct reports?
Who does this position report to?
VP of Healthcare Services
What are the 3-4 non-negotiable requirements on this position?
US Citizen CA RN License 5 years (or greater) management in a healthcare setting
What are the nice-to-have skills?
HMO experience,TRICARE experience,Masters Degree in Health Care Administration 1) What are the most desirable clinical environments this candidate will have experience in? Answer: For this director level position, experience in managed care is most desirable. The candidates for also have prior acute care experience. Accreditation experience (URAC or NCQA). Previous TRICARE experience would be a benefit. For the director Case/Disease Management, previous management of case/disease managers. 2) How many direct reports would you like the candidate to have successfully manages previously- and what type of management style might be best for the candidate express? Answer: 1) 80-100 direct reports previously managed. 2) Coaching and visionary style. Excellent communication skills, must be perceived as approachable, but can also make and implement decisions without alienating team. 3) What metric is this position judged on being successful? Answer: Experience with developing productivity standards, Utilization Management and/or Case or Disease Management Program Plan development, budget planning, project development and process improvement (six sigma or other), analytical and decision-making skills. Also not changing jobs every 1 - 2 years. 4) What extent of technical suites, Microsoft Excel, etc, should the candidate be comfortable with? Answer: Excel, Word, PowerPoint, Visio 5) What are 2-3 strategic screening questions the vendors might want to utilize in screening for this position? Answer: 1) Describe a process improvement initiative they were involved in and what was their role. 2) What are the key metrics they monitor in their current role. 6) What makes this an attractive position for a candidate!? Answer: Executive leadership committed to Medical Management function. New contract with opportunities to be creative, great team.
What is exciting about this opportunity? Please use this section to describe team and company culture.
Supports a large government contract award for a new geographic region. This contract represents the division's continued growth in the TRICARE sector and will generate several new jobs in the locale.
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