Care Management Director

Job Description

Job Description

SUMMARY: Directs and oversees a team of case managers responsible for patient care coordination. Develops and implements case management programs, including utilization review, intake or discharge planning, and managed care contracting. Evaluates patient care data to ensure that care is provided in accordance with organizational guidelines and standards. Develops clinical care pathways that enhance cost-effectiveness while providing quality care.

Essential Duties and Responsibilities include the following. Other duties may be assigned.

·Works on site Folsom Office with consistent attendance.

·Reviews requests for treatment or procedures

·Conducts case reviews for appropriateness/quality of treatment, cost containment and billing accordingly by group each month.

·Tracks and reports all hours by group and patient for current Case Management patients currently in treatment

·Develops Case Management reporting and tracking of members with trigger diagnosis history currently not in treatment and develops treatment plans to save the member and group benefit dollars.

·Maintains communication between insured, medical provider, and insurance company.

·Develop strategy, goals, & objectives for each new client.

·Provides statistical case reviews and generates utilization reports

·Examine DRG pre-certification, certification of admissions, and continued stay.

·Act as a liaison between Medical and Utilization Review departments regarding medical review issues.

·Communicate with other departments and personnel to facilitate proper and adjudication of claims.

·Review medical information from various out of state facilities for medical necessity.

·Maintain medical standards for all clients.

·Communication with hospitals, physicians, and subscribers regarding certification of hospital admissions and outpatient services.

·Makes corrections to reports, format of documentation, etc - Spelling, formatting, grammar, inconsistencies in the report

·Meets with Management team about current processes and implementing new processes

·Will serve as a resource to less experienced staff.

·Develops relationships with physicians, healthcare service providers, and internal and external customers to help improve health outcomes for members.

·May access and consult with peer clinical reviewers, Medical Directors and/or delegated clinical reviewers to help ensure medically appropriate, quality, cost effective care throughout the medical management process.

·Educates the member about plan benefits and contracted physicians, facilities, and healthcare providers. Refers treatment plans/plan of care to peer clinical reviewers in accordance with established criteria/guidelines and does not issue medical necessity non-certifications.

·Maintains compliance with regulation changes affecting utilization management.

·Reviews patients’ records and evaluates patient progress.

·Documents review information on the computer. Enters billing information and/or cost containment for services.

·Responds to complaints from UR guidelines.

·Facilitates educational programs and advises physicians and other departments of regulations affecting utilization management.

·Records and reports all information within scope of authority

·Performs administrative duties; receives, logs in and files a variety of reports, client charts, client interactions and other documents.

The Medical Management Director will manage and delegate, when appropriate, the following activities:

·Working with management to develop business process analyses

·Develop recommendations for appropriate solutions.

·Validate and perform quality assurance.

·Create or revise analytical approaches to reflect current priorities and circumstances.

·Develop, analyze, and implement resource, staffing, capacity, and project plans. Mobilize project teams. Manage the team with the project plan.

·Develop plans or proposals that include cost/benefit analysis, policy, financial, operational, and organizational implications.

·Report to executive management in a manner that discusses progress against the plan, barriers, risks, contingencies, and costs.

·Conduct group facilitation and individual interviews to identify functional requirements, and identify critical issues.

·Exercise discretion, tact, and judgment when working with internal and/or external departments.

Knowledge, Skills, & Abilities:

· Excellent communication skills, both verbally and in writing are critical.

·Knowledge of principles, practices, and current trends in nursing as well as best practices in quality assurance.

·Knowledge and application of state and federal laws, statutes, and regulations; excellent analytical skills; ability to work as part of a team and be self-directed; and intermediate knowledge of Word and Excel.

·Experience in project consulting, analysis, and management.

·Communication qualifications include demonstrated verbal and written communication skills and ability to present information effectively, tailor presentations to a wide variety of audiences (including executive management), present complex concepts, and recommendations clearly for management decision-making purposes.

·Ability to comprehend, interprets, and applies BRMS policies; ability to coordinate a team for effective results; ability to continually adjust in a dynamic environment; and ability to work as a member of a team.

Supervisory Responsibilities: Will directly supervise employees assigned to the Medical Management Department. Will be responsible for all supervisory duties including time & attendance, coaching, disciplinary actions, and performance appraisal.

Qualifications: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and/or Experience:

Bachelor’s in nursing

National Medical Case Management Certification

RN License

1-3 years supervisory experience

Language Skills: Ability to read, speaks, and writes effectively in English. Ability to interpret documents such as safety rules, memos, letters, and procedure manuals. Ability to draft routine reports and correspondence. Ability to speak effectively before customers or employees of organization. Ability to effectively address or resolve customer service issues within guidelines of the position.

Mathematical Skills: Ability to add and subtract, multiply, and divide with 10's and 100's.

Reasoning Ability: Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Ability to deal with problems involving several concrete variables in standardized situations.

Certificates, Licenses, Registrations:

Current California RN License: REQUIRED

National Medical Case Management Certification: REQUIRED

Physical Demands: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this Job, the employee is regularly required to sit for extended periods in front of a computer. The employee is frequently required to reach with hands and arms and talk or hear. The employee is occasionally required to stand; walk and use hands to finger, handle, or feel. The employee may frequently lift and/or move up to 10 pounds. Specific vision abilities required by this job include close vision, distance vision, peripheral vision, depth perception and ability to adjust focus. This position requires the employee to work in the office.

Work Environment: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The noise level in the work environment is usually moderate.

Company DescriptionEstablished in 1993, Benefit & Risk Management Services, Inc. (BRMS) is a leading benefit administrator and healthcare risk manager that delivers innovative technology and administration solutions to control rising healthcare costs.

One of the first to introduce employee benefit administration technology solutions, our services are powered by our exclusive Virtual Benefits Administration System (Vbas) a proprietary database and administration system that allows employers to save time and money by automating management of the benefit supply chain and empowering employees to self-service their benefits

Company Description

Established in 1993, Benefit & Risk Management Services, Inc. (BRMS) is a leading benefit administrator and healthcare risk manager that delivers innovative technology and administration solutions to control rising healthcare costs.\r\n\r\nOne of the first to introduce employee benefit administration technology solutions, our services are powered by our exclusive Virtual Benefits Administration System (Vbas) a proprietary database and administration system that allows employers to save time and money by automating management of the benefit supply chain and empowering employees to self-service their benefits