Director (RN) - Care Management
Director (RN) Care Management
Fort Worth, Texas
Responsible for the planning, organizing, implementation, and management of all medical management functions. This position is also responsible for monitoring the Case Management Program and LTSS Program to assure compliance with the requirements of external regulatory and accreditation agencies.
Develops and maintains policies and procedures for the Care Management Program, including utilization review (precertification, concurrent, retrospective), discharge planning, catastrophic case management, long term services and supports, and case management for disease management programs.
Maintains daily oversight of all Clinical Programs to ensure compliance with departmental policies and procedures as well as all contractual and regulatory requirements.
Analyzes and trends in variances and makes appropriate recommendations for further review or action. Prepares and submits written monthly medical management data in accordance with Health Plan reporting requirements.
Facilitates liaison relationships with payor representatives for which the Health Plan has delegated utilization management agreements. Prepares reports as required by the payor.
Determines department structure and staffing, Develops job descriptions for the Care Management staff and reviews these annually. Establishes and oversees staff development and evaluation programs. Provides staff with ongoing training, in-services, and continuing education opportunities to enhance performance and improve service by the Care Management Department to its internal and external customers
Develops, implements, and manages the Health Plans Medical Necessity Denial and Appeal processes. Assures processes are in compliance with all regulatory requirements.
In collaboration with the Health Plan Medical Director, develops, implements, and manages the Health Plan Quality Management program for the Care Management Department. Develops, implements, and directs an interrater reliability process to ensure standardization in the utilization review process for non-physician reviewers.
Works directly with the Assistant Vice President of Network Management to identify needs for additional providers as well as to identify provider and staff education needs.
Prepares and submits annual capital and operating budgets. Manages approved monies to ensure that a positive variance is maintained.
Bachelor of Science in Nursing; Masters preferred
7+ years experience
Texas Registered Nurse License
Case Management experience
Utilization Review experience
The ideal candidate will have the following experience:
Managed care preferably Medicaid
Leadership and developing managers
Process improvement/ gaining efficiencies
Team buildingCompany Description
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