Director, Outpatient Case Management

Responsible for management and oversight of Case Management operations and related programs related to the provision of the full scope of case management and chronic illness management to Enrollees assigned to this Program and employees assigned to the Department to carry out the responsibilities of the Program.

The position is directly responsible for managing the daily operations of the Program and Department and interfacing with Employer's programs such as Inpatient, SNF, home health care services, hospice, TOC, Preauthorization, Contracting and Claims.

Responsible for the development of processes to oversee ambulatory case management including systematic processes for documentation and auditing and development of, programs that maximize quality while utilizing appropriate resources within the members' benefit plans and established matrix's.

The Director of Case Management is responsible, in collaboration with other members of Medical Management Department Management Team, for ensuring the highest standards of clinical outcomes, quality standards, resource utilization and patient satisfaction for Enrollees of Regal Medical Group.

1. Identifies and develops Program and Department policies and procedures and ensures compliance and consistency throughout RMG regional sites.

2. Develops, monitors, and analyzes Program and Department reports and identifies trends to improve clinical and utilization and quality outcomes.

3. Develops and coordinates Program and Department strategies for ensuring the delivery of care in the most cost effective setting.

4. Manages and monitors Enrollees assigned to case management programs to ensure efficient and timely delivery of care, timely referrals, and moving the Enrollee's treatment plans through the care continuum.

5. Collaborates with the RMG Medical Directors to analyze data and implement programs that will improve Enrollee outcomes.

6. Motivates, instructs, mentors, audits and leads and constantly improves the quality of service and clinical outcomes rendered by the Employer's the Case Management staff.

7. Develops annual Program and Department goals and objectives focused on improving patient outcomes and efficiency.

8. Implements tools and processes that direct and role model a high level of customer service behavior toward Enrollees.

9. Works collaboratively with the entire Medical Management team to ensure that Employer company goals as well as compliance with regulatory and health plan requirements are met.

10. Has direct oversight responsibility and accountability of the Program and Department case management and ancillary staff . At Employer's discretion and in consultation with Director, Director's service area jurisdiction and responsibilities may be expanded and/or changed.

11. Training, mentoring, auditing of the clinical competency, productivity, contribution, customer service interaction of Program and Department professional and non professional staff. Act as a resource to all staff members of the Program and Department.

12. Act as a resource for hospitalists, SNFs, outpatient utilization management staff, home health care agencies, Employer home-visit physicians and nurse practitioners.

13. Provide regular audit reports on Program and Department staff and action plans to improve efficiency and efficacy.

14. Assume on call responsibilities to support and act as a resource to Program and Department staff, and ensure the timely response to urgent/emergent Enrollee needs

15. Other responsibilities to be determined by mutual agreement in consultation with Senior Leadership of Clinical Operations

16. All other duties as directed by management.

1. Previous management experience necessary.

2. Must have experience in managing high risk cases.

3. High level knowledge of Case Management processes and principles including Duals and NCQA

4. Prior experience in MSO environment preferred.

5. Ability to work with all levels of management.

6. Must have excellent communications skills both verbally and written.

7. Must have excellent organizational skills.

8. Must have prior experience with project development and implementation.

9. Must have working knowledge of MS Office environment, and EZ Cap

10. Requires current CA driver's license and car insurance

11. Requires RN license, CCM certification preferred.

1. Previous management experience necessary.

2. Must have experience in managing high risk cases.

3. High level knowledge of Case Management processes and principles including Duals and NCQA

4. Prior experience in MSO environment preferred.

5. Ability to work with all levels of management.

6. Must have excellent communications skills both verbally and written.

7. Must have excellent organizational skills.

8. Must have prior experience with project development and implementation.

9. Must have working knowledge of MS Office environment, and EZ Cap

10. Requires current CA driver's license and car insurance

11. Requires RN license, CCM certification preferred.