The VP, Care Management/Utilization Management is responsible for oversight and management of the health plan's Clinical Operations Team including Utilization Management and Care Management in accordance with HSCSNs CASSIP contract. This position works collaboratively with the Chief Medical Officer to develop and implement processes to effectively manage clinical policies to meet healthcare cost, quality targets, and implements a program of care coordination and utilization management as defined in the CASSIP contract. Oversees the provision of a range of services and benefits in accordance with the CASSIP contract from multiple network providers. Goal of coordinating covered health care services with other community services available in the District of Columbia including educational, social, disability services. Promotes linkage between utilization management, care coordination and quality improvement activities. Acts as a role model for clinical staff, promoting education, development and adoption of the CQI process. Promotes teamwork, and works independently, while maintaining appropriate communication with CMO and Senior Leadership.
Essential job duties:
- Works with the Clinical Operations Team to achieve successful implementation of HSCSN clinical strategy and direction.
- Develops and implements effective and efficient standards, protocols, processes, decision support systems, reporting and benchmarks that support ongoing improvements of clinical operations functions and promote quality cost effective health care for HSCSN members.
- Monitors and evaluates key care coordination processes and practices to ensure achievement of the organizations mission and goals and improve health outcomes of members.
- Mentors, guides and develops skills of clinical team members in a consistent and effective manner.
- Develops initiatives to achieve increases in quality scores.
- Develops departmental budgets and ensures budget targets are met.
- Manages implementation of analytical studies that quantify the benefits of CASSIP programs to ensure that resources are appropriately allocated, operational controls exist, and efficiencies are maximized.
- Facilitates integration of care coordination with CASSIP program partners Child & Family Services Administration (CFSA), Department of Youth Rehabilitation Services (DYRS), Department of Behavioral Health (DBH), Office of the State Superintendent of Education (OSSE) and Katie Beckett.
- Continually refines operational processes and champions review of team processes, workflows and activities.
- Articulates project requirements and anticipated outcomes to the senior management team and board for identified projects/strategies to improve the efficiency of clinical operations teams to meet cost and quality goals.
- Accountable for ensuring compliance with contractual, accreditation and regulatory requirements for Care Management and Utilization Management teams.
- Participates personally or assigns appropriate staff to Quality Committees and external Community Committees to represent the clinical departments.
- Ensures effective inter-departmental collaboration and interaction between clinical staff and other departments.
- Ensures that monthly auditing of clinical staff is performed and appropriate actions and/or coaching occur.
- Responsible for oversight of clinical training activities and outcomes.
- Responsible for clinical related delegation oversight monitoring
- Develops and maintains a positive working relationship on behalf of HSCSN with the District of Columbia Office of Medical Assistance Administration.
- Works with IT staff to define care management systems requirement, which meet regulatory and analytic needs.
Previous experience in supervising and performing utilization management and care management functions, preferably in MCO setting. At least five years management experience in utilization management or case management with sound clinical background.
Certified Case Manager or equivalent credential preferred.
Advanced degree in business or health care administration required.
DC Residents are encouraged to apply!