General Summary of Position
Responsible for the implementation, integration, and overall operational direction of the utilization management and case management programs within MedStar Family Choice. This involves organizing, directing, assessing, and evaluating a clinical system that manages cost and quality patient care outcomes. The role acts as the system-level representative to ensure integration of the case management program and to meet objectives for quality and cost-effective outcomes.
We recruit, retain, and advance associates with diverse backgrounds, skills, and talents equitably at all levels.
Primary Duties and Responsibilities
- Develop department goals, objectives, policies, procedures, and performance standards. Ensure compliance with policies, procedures, and regulations. Oversee policy development and updates annually.
- Participate in strategic planning for MedStar Family Choice. Initiate programs to improve quality and manage medical expenses. Serve as a resource for clinical issues. Ensure compliance with standards.
- Understand and manage the care management software system. Coordinate training and testing for upgrades. Support staff and vendors using the software.
- Manage the department's budget, oversee audits, and develop operational plans.
- Identify network needs, collaborate with provider relations, and develop contractual relationships.
- Oversee clinical services and benefits, training programs, and staff development.
- Participate in quality improvement teams, community outreach, and represent the department in various forums.
- Oversee delegated vendors, review reports, and ensure adherence to guidelines and regulations.
- Educate providers on authorization, case management, and disease management. Address network issues promptly.
- Provide coaching and support to staff. Conduct performance reviews and facilitate professional development.
- Ensure adherence to NCQA guidelines for UM and case management. Conduct chart audits and analyze key data metrics.
- Develop and evaluate case management and care programs in compliance with standards.
- Coordinate quality studies and measure member satisfaction, making improvements as needed.
- Hire, train, and evaluate staff. Maintain performance standards and communication.
- Serve as the point of contact for DHCF and collaborate with IS, data analysts, and report writers to develop reports.
- Develop strategic plans to enhance healthcare delivery aligned with organizational and regulatory goals.
Minimum Qualifications
Education
- Bachelor's degree in Nursing required
- Master's degree in Nursing preferred
Experience
- 3-4 years of case management experience and 3 years of supervisory experience required
- Clinical management or administration experience in health services required
- Behavioral health experience and clinical director experience preferred
Licenses and Certifications
- RN license in the District of Columbia required
- CCM certification required
Knowledge, Skills, and Abilities
- Excellent verbal and written communication skills
- Proficient in computer skills
Position hiring range: $118,331 - $230,172