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The Director of Medical Management is responsible for the overall operations of the First Choice Health Medical Management department. This position provides leadership and strategic direction to staff and management in the current medical management activities, and in the development of new products and services. The Director of Medical Management works closely with the CMO/ Medical Directors in the development of policy/guidelines for medical management activities.
Provide leadership and manage the operations of the Medical Management (MM) department for all lines of business including risk management.
Provide administrative oversight for TPA and PPO with matters concerning UM, CM, HPS, Pharmacy and Appeals. Act as liaison for MM with the Account Executives.
Responsible for successful MM compliance with regulatory and accreditation standards such as URAC, NCQA (as appropriate), and Department of Labor.
Responsible for maintaining appropriate staffing levels according to enrollment population, approved staffing ratios, and performance indicators.
Oversee the Pharmacy Program with preferred vendors and consultants. Works closely with Manager of Quality, Health Promotion, and Pharmacy to manage vendor relationships, contracts, and new business opportunities for Health Promotion and Pharmacy.
Responsible for the annual review/updating of all MM policies and procedures, and Medical Policies of all the teams, in conjunction with the CMO.
Responsible for development of the annual MM department Budget in collaboration with the CMO, using staffing ratios and membership.
Respond to Account Executives and client?s HR staff concerning medical management questions or request for data/reports.
Provide clinical oversight and guidance to claims, compliance, and benefit set-up to assure accurate reimbursement of claims.
Develop and review the annual MM Work Plan, MM Work Plan Evaluation, Program Evaluations, Program Descriptions and the annual Clinical Quality Work Plan and Program Review, in conjunction with the CMO/Medical Directors.
Monitor and evaluate available utilization data for over-and-under utilization and cost trends.
Provide input on strategic medical management and clinical quality to the CMO.
Update the Pre-Cert list annually or more often if necessary with associated codes and collaborate with TPA Operations for successful implementation I Bridge, Diamond, and the Web.
Review RFP applications, the proposed benefit plan document, and answer MM questions in RFP.
Assist with Finalist presentations for prospective groups when needed.
Lead and participate in staff medical committees and other work groups to assure forward movement in clinical management issues and quality activities, in conjunction with the CMO.
Work closely with IT on systems established to support operations for medical management such as Diamond and Bridge, and with Health Care Analytics department for Access databases.
Collaborate with the HPS Manager in designing ongoing clinical quality projects and implementing and monitoring new quality improvement strategies, in collaboration with CMO/Medical Director, and other managers.
Participate in community collaborative clinical quality and administrative simplification activities (One Health Port), in conjunction with the CMO, or delegate these activities to a Manager.
Other activities as assigned by the CMO.
Current, unrestricted Washington State RN license.
Bachelors degree required; Masters degree in a Healthcare related field preferred.
Minimum three years experience in the HMO/PPO health care industry.
Minimum three years supervisory experience of professional staff.
Prior experience in the development and implementation of case management and utilization management program. Strong written, verbal, physical assessment and interpersonal communication skills.
Strong organizational, analytical and time management skills.
Proficiency in PC Applications including Word, Excel, PowerPoint and Outlook.
Ability to proactively manage changing fast-paced environment.
Become a First Choice Health employee and enjoy our generous benefit package. We offer competitive benefits that are much beyond the traditional basics.Click here to learn more about our competitive benefit package.
How to Apply
Please submit your resume to firstname.lastname@example.org.
Additional information about our company may be found on our website www.fchn.com