Director, Government Care Management
PacificSource

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PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, national origin, sex, sexual orientation, gender identity or age.

Diversity and Inclusion: PacificSource values the diversity of the people we hire and serve. We are committed to creating a diverse environment and fostering a workplace in which individual differences are appreciated, respected and responded to in ways that fully develop and utilize each person's talents and strengths.

Position Overview:

The Director of Government (Govt) Care Management is responsible for leading, developing, and operationalizing care management/care coordination within the population health strategy for our Medicare and Medicaid LOB's. Provide oversight to ensure the company's government-related care management and contractual performance objectives are met, programs and resources are used effectively and successful execution of both short- and long-term population health goals. Reports to the Sr. Director Care Management.

Essential Responsibilities: .

• Responsible for hiring, staff development, coaching, performance reviews, corrective actions, and termination of employees. Provide feedback, including regular one-on-ones and performance evaluations, for direct reports.
  
• Responsible for oversight, management, development, implementation, and communication of department programs.
  
• Develop annual department budgets. Monitor spending versus the planned budgeted throughout the year and take corrective action where needed.
  
• Coordinate business activities by maintaining collaborative partnerships with key departments.
  
• Responsible for process improvement and working with other departments to improve interdepartmental processes. Utilize lean methodologies for continuous improvement. Utilize visual boards and daily huddles to monitor key performance indicators and identify improvement opportunities.
  
• Actively participate as a key team member in Manager/Supervisor meetings.
  
• Actively participate in various strategic and internal committees in order to disseminate information within the organization and represent company philosophy.
  
• Lead, supervise and motivate to operationalize best practice recommendations, evidence-based standards, and regulatory requirements to ensure adherence to CMS, NCQA, Oregon Health Authority.
  
• Foster teamwork, encourage critical thinking, provide clear and consistent direction, and provide staff with growth and development strategies.
  
• Develop and implement and monitor policies and strategies to achieve the growth and profitability goals established in accordance with strategic business objectives, professional standards and applicable regulatory requirements.
  
• Identify, analyze, organize, and solve problems and issues in a timely, effective manner; use data and input from others to make sound, timely decisions.
  
• Endorse member centered care as a philosophical approach to inform Care Management strategies and programs. Champion motivational interviewing as the foundation of our overall Care Management program. Resolve escalated issues arising from operations and requiring coordination with other departments.
  
• Establish a culture of excellence in performance and innovation that optimizes opportunities to create new models and processes that better serve patients and their families, with the goal of reducing medical spend and enhancing quality metrics/outcomes.
  
• Work with IT and Analytics on prioritization of software changes and needed Informatics upgrades. Liaison between Medical Directors and IT / Informatics / Analytics to support appropriate reporting packages for internal and external use.
  
• Participate in management planning, Request for Proposals (Medicare/Medicaid applicable oversight), complete annual reports as required by states we serve.
  
• Provide oversight and expertise to continue to integrate physical, behavioral, and oral health programs.
  
• Monitor, evaluate, and report performance data for daily management systems, care management programs, compliance and other metrics as they relate to strategic initiatives and company objectives.
  
• Responsible for oversight of the D-SNP program and associated Model of Care deliverables. Ensure adherence to applicable regulatory requirements and successful strategic deployment of resources. Evaluate and help inform opportunities for program expansion.
  
• Continually seek opportunities to for scale-ability. Lead efforts to standardize care management programs and approaches in alignment with the broader Care Management strategy.
  
• Ensure collaboration and alignment with quality metrics, quality programs and other clinical quality initiatives as needed.
  
• Ensure inclusion of the member voice as a centralized focus to inform CM programming. Participates in ongoing process improvements related to the enhancement of the member experience across the enterprise.
  

Supporting Responsibilities:

• Serve on designated committees, teams, and task groups, as directed.
  
• Work with Medical Directors in responding to inquiries or complaints and pertinent report preparation for other review functions.
  
• Work collaboratively with the UM Director to ensure seamless care transitions across the care continuum and to establish best practice strategies for managing members across LOB's.
  
• Participate in and support project teams led by other departments and provide necessary input to support the goals of colleagues.
  
• Meet department and company performance and attendance expectations.
  
• Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
  
• Perform other duties as assigned.
  

SUCCESS PROFILE

Work Experience: At least seven years of experience with varied medical exposure required. Minimum of 3 years management or supervisory experience required. Knowledge and experience with Medicaid and Medicare clinical operations in health plans is required. Experience in case management, disease management, utilization management and program development using evidence-based medicine required. Prior success in healthcare integration, process development and program implementation is desirable. Additional experience managing complex work processes, including, HEDIS, 5 Star and HCC related projects is highly preferred.

Education, Certificates, Licenses: Clinical Bachelor's degree required. Registered nurse or behavioral health clinician with current unrestricted state license required. Master's degree strongly preferred. Certified Case Manager (CCM) as accredited by CCMC (The Commission for Case Management Certification), or equivalent.

Knowledge: Knowledge and understanding of disease prevention, medical procedures, care modalities, procedure codes, including ICD-10, CPT Codes, health insurance, and CMMS / State of Oregon mandated benefits. Ability to develop, review, and evaluate utilization reports. Knowledge of and demonstrated experience with quality improvement methodology. Experience giving presentations. Organizational skills with solid experience in using computers and various software applications including Word, Excel, PowerPoint, Outlook, SharePoint, Claims and Care management programs, and audio-visual equipment. Ability to work independently with minimal supervision. Ability to deal with members, patients and families at all levels of care and/or crisis. Thorough knowledge and understanding of PacificSource contractual benefits and appropriate available outside contractual benefits. Thorough knowledge of community services, providers, vendors and facilities available to assist members. Ability to use computerized systems for data recording and retrieval. Ability to supervise and manage clinical and support staff. Ability to implement goals and objectives of the department within the context of PacificSource's strategic and management planning. Thorough understanding of PacificSource policies and Health Services Department procedures. Continually seeks to improve quality of service, care, and processes for internal and external customers. Assures patient confidentiality, privacy, and health records security. Accurately interprets contractual benefits. Provides compassionate and confidential service to members/patients. Supports policy and change process, both internal and with providers. Identifies and informs Medical Director of high exposure cases and/or potential reinsurance claims. Keeps the Medical Director apprised of medical management issues. Accountable for service to internal and external customers.

Competencies

• Authenticity
  
• Building Organizational Talent
  
• Coaching and Developing Others
  
• Compelling Communication
  
• Customer Focus
  
• Empowerment/Delegation
  
• Emotional Intelligence
  
• Leading Change
  
• Managing Conflict
  
• Operational Decision Making
  
• Passion for Results
  

Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 30% of the time.

Our Values

We live and breathe our values. In fact, our culture is driven by these seven core values which guide us in how we do business:

• We are committed to doing the right thing.
• We are one team working toward a common goal.
• We are each responsible for customer service.
• We practice open communication at all levels of the company to foster individual, team and company growth.
• We actively participate in efforts to improve our many communities-internally and externally.
• We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community.
• We encourage creativity, innovation, and the pursuit of excellence.

Physical Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.

Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.

This job has expired.