Insurance and Risk Management Director jobs in Morgantown, WV

The Director of Case Management provides leadership, management, oversight, and assessment of all aspects of clinical program management and is responsible for ensuring quality provision of member driven care continuum programs while ensuring delivery of essential services that address the total health care needs of The Health Plan members. The Director of Case Management works collaboratively with the VP of Clinical Services, Director of Utilization Management, AVP of Population Health and the Medical Directors, as well as other interdisciplinary team leaders to plan, organize, coordinate, develop the vision, perform implementation and measure the outcome of all population health driven, care continuum programs based on both governmental and non-governmental lines of business to ensure compliance to the requirements of all regulatory and accreditation bodies relevant to clinical management.

Required:

• Registered Nurse with a minimum of 5 years clinical experience.
• At least two years of experience should be in a management capacity.
• Minimum of a Bachelor's of Science degree in Nursing or willingness to obtain within 2 year of hire.
• Holds active and unencumbered Ohio or West Virginia multi-state registered nurse license.
• Minimum of five years in a managed care organization.

Desired:

• Should possess public speaking and excellent written communication skills, motivation and initiative, and ability to work independently.
• Should possess superior work ethic.
• Experience in writing policies and procedures.
• Proven leadership abilities.
• Should possess strong verbal, written, analytical, and interpersonal skills.
• Should be flexible and able to multi-task, work in a fast paced environment and adapt to changing processes.
• Self-starter with strong entrepreneurial skills.
• Certification in related area preferred, Certified Case Manager (CCM).

Responsibilities:

• Oversees medical and Care Continuum operations.
• Provides direct supervision to the managers and supervisors.
• Develops and monitors medical management staff care continuum training program.
• Participates on all clinical services committees.
• Development and continual review and revision of all care continuum processes, policies and procedures within the department.
• Develops and enhances system of management reporting and metrics to be utilized for productivity, adherence, and outcome measurements to provide relevant information on overall effectiveness in care continuum areas.
• Ensure department optimizes care continuum work flow efficiencies to meet company objectives
• Ensures that all medical care continuum programs are delivered consistent with applicable internal policies and procedures as well as applicable CMS, BMS, NCQA or other regulatory agency requirements.
• Ensures appropriate care continuum programs are in compliance to quality outcomes e.g. STAR measures, HEDIS, CCIP, QIP and PIPs.
• Responsible for medical management/behavioral health annual risk assessment related to care continuum programs.
• Collaborates with the CMO, VP of Clinical Services, Director of UM and AVP of Population Health on initiatives and interventions to ensure cross-functional and inter-departmental alignment with organizational goals.
• Leads medical management and behavioral health care continuum program integration with provider health systems.
• Implements and monitors medical management and third party care continuum program software.
• Provides input into clinical services medical/evidence based care continuum program criteria.
• Leads clinical services care continuum program compliance and NCQA initiatives.
• Interacts with government agencies, health systems, and employer groups to facilitate medical care program integration.