Director, DSNP Care Management

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Negotiable

Permanent

Description

JOB DESCRIPTION



Director of DSNP Care Management



DEPARTMENT: Medical Management



STATUS: Regular Full-time, FLSA Exempt



LOCATION: Tacoma, WA



REPORTS TO: VP Care Management



JOB SUMMARY



The Director of DSNP Care Management leads the DSNP Clinical Care Management team for the DSNP line of business. This position is responsible for developing, implementing, refining, maintaining and execution of DSNP Care Management services, programs, policies and services in compliance with regulatory (CMS, HCA, NCQA) requirements. Responsibilities include the functional areas of Care Management, Disease Management, Transitions and Quality Assurance.



The Director of DNSP Care Management oversees clinical focused applications and systems including implementation, ongoing maintenance, support, enhancement, and education to clinical staff and for assessing current and future technology needs for clinical staff and the impact of the technology on assigned processes.



ESSENTIAL DUTIES & RESPONSIBILITIES



* Provides effective administration and operational team leadership of the DSNP care management program including strategic planning, project management and fiscal management

* Coordinates and communicates care management objectives with contracted providers/affiliates and ancillary vendors.

* Keeps leadership advised on current events which may affect Optum Care Network as a whole

* Evaluates financial and care trends concurrently and retrospectively and implements plans to improve resource utilization, outcomes and reduce financial burden

* Oversees the development, implementation and review of policies and procedures (including desk manuals) based on local, state, federal, contract and NCQA standards

* Responsible for health plan delegation, contract compliance and audits related to DSNP Care Management

* Analyzes departmental data and recommends system or workflow improvements when appropriate

* Triages departmental system issues and involves appropriate staff and departments on problem resolution

* Leads clinical focused system installations and enhancements

* Ensures adherence to policies, procedures and regulations

* Directs activities to implement and manage clinical quality improvement initiatives related to utilization/affordability

* Manages and maintains staffing within budget

* Responds to issues and concerns escalated from staff or Executive Team

* Prepare and present all relevant clinical data to UM/QM committee and Optum Care Network leadership team to comply with health plan delegation requirements

* Prepare and present ongoing education to the care management staff in compliance with health plan delegation requirements

* Responsible for the DSNP care management staff employment life cycle

* Maintains confidentiality of patient and all related entity business matters of the organization and its partners



KNOWLEDGE, SKILLS AND ABILITIES



* Keeps current on all NCQA, local, state and federal health care regulations, incorporates changes in regulations to ensure compliance by staff



* Working knowledge of:



* Case, Disease, and Care Management services

* Health care delivery system

* InterQual/Milliman criteria guidelines

* Medicare/Medicaid commercial payor guidelines



* Demonstrated knowledge of PC applications including MS Office Suite

* Skill in writing clear, grammatically correct, easyto-use instructional documentation

* Ability to analyze complex problems and formulate plans, solutions and courses of actions

* Knowledge of specific communication needs with the ability to listen actively and respond to internal and external customers in a timely, competent manner both verbally and in writing

* Demonstrated skill in learning and fully utilizing information technology systems

* Ability to work accurately with detail

* Knowledge of technical resources within the organization for needed information

* Ability to judge appropriate information to be conveyed to different levels of management

* Skill in working with a team; collaborating with colleagues

* Ability to establish and maintain cooperative working relationships with individuals at all levels of the organization

* Skill in working effectively under deadlines, frequent interruptions and changing priorities



MINIMUM QUALIFICATIONS



EDUCATION: Degree in Nursing (RN) BSN Preferred



EXPERIENCE:



* 5 years broad based clinical experience

* 5 years management experience of professional and technical staff

* 5 years nursing leadership experience in developing Care Management functions



CERTIFICATION/LICENSE:



* Current unrestricted RN License in the State of Washington

* Current drivers license



EQUIPMENT USED



Office equipment, computer, personal vehicle



MENTAL & PHYSICAL DEMANDS/WORKING CONDITIONS



* Mental Effort: Must be able to work effectively as a member of Optum Care team; work is detailed and complex with multiple competing priorities, deadlines and internal and external customers



* Physical Requirements: Work is primarily in office environment requiring ability to see and hear and communicate as well as operate personal motor vehicle



* Working Conditions: Work is performed both in an office setting and at clinic locations; noise level may be moderate or loud on occasion; work may be required outside normal business hours



_The job description does not constitute a written or implied contract of employment. Optum Care Network reserves the right to revise or change job duties and responsibilities as the need arises. _
  • 1
  • Negotiable
  • None
  • None
  • Re-11212
  • Permanent
  • 3

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