Medical Management Director (Encino, CA)

As a part of the Tenet and Catholic Health Initiatives family, Conifer Health brings 30 years of healthcare industry expertise to clients in more than 135 local regions nationwide. We help our clients strengthen their financial and clinical performance, serve their communities and succeed at the business of healthcare. Conifer Health helps organizations transition from volume to value-based care, enhance the consumer and patient healthcare experience and improve quality, cost and access to healthcare. Are you ready to be part of our solutions? Welcome to the company that gives you the resources and incentives to redefine healthcare services, with a competitive benefits package and leadership to take your career to the next step!

JOB SUMMARY

The Director of Medical Management provides leadership, management and operational oversight of Medical Services and is responsible for managing the prior authorization, utilization and case management process ensuring delivery of essential services that address the total healthcare needs of members. The Director of Medical Services works under the direction of the Senior Director, Medical Services. The Director works with the Senior Director and Medical Directors to plan, organize, coordinate and develop the vision and implementation of all Medical Services programs. The programs are based on government contracts and commercial lines of business. The programs ensure adherence to the requirements of the regulatory and accreditation bodies relevant to Medical Services.

Director maintains direct accountability for reporting, compliance, financial analysis, planning and coordination of efforts with other departments to assure effective operations of the clinical programs.

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Implements and manages health care managementâ��s utilization, cost, and quality objectives.
• Ensures program compliance and identifies opportunities to improve customer service and quality outcomes.
• Demonstrates leadership abilities in a clinical operations environment
• Develop and meet contractual reporting obligations related to area of accountability, and participate as a subject matter expert on contract changes and deliverables, as required to meet contractual and customer expectations.
• Development and continual review and revision of all processes, policies and procedures with the department.
• Develops reports and metrics to be utilized for productivity, adherence and outcome measurements.
• Ensure departments optimize workflow efficiencies to meet company objectives.
• Provides supervision, guidance and mentoring to managers and staff.
• Ability to communicate effectively with a wide range of individuals, both internal and external.
• In-depth knowledge of managed care operations, benefit design and UM/CM techniques.
• Ability to work with internal customers to facilitate programs.
• Provides input to business leaders and leadership regarding program enhancements, operational improvement and potential benefits of the improvements.
• Other duties as assigned.

SUPERVISORY RESPONSIBILITIES

• Direct Reports (titles) 3+ Managers of UM, PA and CM
• Indirect Reports (titles) 50+ Case Managers, Coordinators, and Nurses

Qualifications -

• Advanced knowledge of Medicare and Medicaid programs as well as established clinical acumen
• Advanced knowledge of commercial health plan programs
• Advanced computer skills with proficiency in MS Office applications especially MS Excel
• Proven capability to work with people at all levels in an organization
• Excellent training and presentation skills with solid communication capabilities and practices, oral and written
• Strong interpersonal, verbal, written, and administrative skills
• Demonstrated effective organizational skills
• Excellent communication, writing, proofreading and grammar skills
• Strong attention to detail and accuracy, excellent Evaluative and Analytical skills
• Strong teamwork, interpersonal and customer service skills
• Familiarity with statistics, especially around predictive modeling and risk
• Ability to understand complex applications and derive solutions

EDUCATION / EXPERIENCE

• 3 - 5 years of experience in a Management or Director role in a Health Care setting
• 5+ years of experience as a Manager or Director in a Managed Care Environment
• CCM or other like certification
• Strong knowledge of URAC and NCQA guidelines
• CA RN license required
• Prior experience managing UM in a health plan or provider system required
• MBA or Masterâ��s degree strongly preferred
• Prior experience with TOC and Model of Care strongly preferred
• Prior experience interacting communicating issues and opportunities with physicians preferred
• Prior experience with Medicaid population a plus

REQUIRED CERTIFICATIONS/LICENSURE

• Licensure must be current and unrestricted in the appropriate jurisdiction

PHYSICAL DEMANDS

• Must be able to work in sitting position, use computer and answer telephone
• Ability to travel
• Includes ability to walk through hospital-based departments across broad campus settings, including Emergency Department environments

WORK ENVIRONMENT

• Office Work Environment

TRAVEL

• Approximately 25% travel may be required

Employment practices will not be influenced or affected by an applicant�s or employee�s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.