Director, Medical Management – Complex Care
Open due to promotion! Strategic leadership role will provide direction and guidance in medical management and quality for the Medicare product line in this market. You will join a member-centric team of clinicians committed to quality care.
Director will develop and implement market focused clinical programs to improve health and quality outcomes for Medicare member and assure utilization management best practices. Medicare is NOT required for this – strong leader with commercial insurance experience is great.
- Ensure compliance with all Centers of Medicare/Medicaid Services (CMS) clinical, quality, and service requirements.
- Act as a liaison between the market and corporate office for Medicare business.
- Establish clinical operational objectives, quality improvement goals, and related policies and procedures
- Oversee all accreditation and oversight requirements and ensure policies and procedures are compliant with NCQA and CMS
Ideal Candidate :
- Bachelor's degree in Nursing, Healthcare Administration or related field.
- 7+ years of quality improvement, prior authorization, concurrent review, and case management operations experience in a managed care setting.
- Knowledge of commercial insurance, Medicare or Medicaid coverage rules and parameters for medical necessity decision making.
-Previous management experience including responsibilities for hiring, training, assigning work and managing performance of staff.
-Knowledge of CMS requirements for NCQA oversight requirements preferred
License/Certification: RN required!
** This is an office-based position.