The primary purpose of this position is to manage the utilization management and case management clinical programs and operations for the Health Plans. Medical Management ensures members access to and satisfaction with quality health care, as well as appropriate utilization of health care services. As a key leadership role, this position will work collaboratively with all members of the leadership team to provide cross organizational leadership. This position performs all related duties in a manner that is consistent with and in support of the organizations mission, vision, values and goals.
Responsible for the leadership of Medical Management, which includes Utilization Management departments within the Health Services division as well as Case Management as it relates to the Plans Medicaid (AHCCCS) and Healthcare Group of Arizona (HCGA) populations.
Responsible for the leadership of Case Management, which includes the Case and Disease Management, Maternal-Child Health, and Behavioral Health departments in the Health Services division in conjunction with the Director of Care Management of Medicare. The position will focus on ensuring appropriate utilization and case management, which focuses on helping members to obtain the right care in the right place at the right time to achieve better overall health status. It is the evaluation of the appropriateness, medical need and efficiency of health care services, procedures and facilities. The evaluation is according to established criteria and guidelines, and under the provisions of an applicable health benefits plan. It includes proactive procedures and processes, such as pre-certification, concurrent planning and reviews, peer reviews, discharge planning, and clinical case appeals.
The position will be responsible for ensuring cross collaborative integration with other key Medical Management functions, such as care management, condition management, behavioral health, maternal-child health, quality management, pharmacy, as well as non-clinical collaboration with Health Plan operational departments. As a member of the senior leadership team, the Director of Medical Management provides strategy and direction of Medical Management operations, assuring efficient and effective operations, ultimately impacting positive financial and clinical outcomes. This position will be a member of the Directors, Operations and other key leadership teams within the organization to ensure consistent leadership, collaboration and communication across the organization.
Collaborates with the Director of Quality and Performance Improvement in designing, implementing, and measuring the efficacy of interventions that were implemented to as a result of data analysis or recommendations from quality investigations. Oversees the submission of required data internally and externally, such as to AHCCCS. Assures data meet requirements of AHCCCS and HCGA. Protects the financial interests of the organization and clinical interests of members through continuous review, oversight and management of all aspects of the Medical Management areas within the organization, which includes utilization, and case management activities, inclusive of services affecting AHCCCS and HCGA members. Monitors and assesses the effectiveness of both CM and UM interventions, using metrics/reports to inform decisions and improve interventions. Works with the Medical Director, in the development and ongoing improvement for Utilization and Case Management programs for managed care patients and providers. Seeks to continually improve member satisfaction and health outcomes.
Oversees the Medical Management Systems Department that retrospectively clinically reviews claims submissions, coordinates data reporting to Medical Management areas, provides training as needed regarding information systems, and coordinates inter rater reliability testing for all Medical Management staff.
Develops effective, well-defined and supported UM processes and functions for Medicaid and HCGA and any other populations served, and manages them collaboratively across the organization. Develops effective, well defined and supported CM processes and functions for Medicaid and Healthcare Group and works collaboratively with the Director of Care Management to support her/his management of dual eligible and Special Needs Population members. Develops and implements business requirements for UM and CM, leveraging technology areas used to support UM and CM delivery, for both internal and on-site delivery. Provides oversight to maintaining appropriate UM and CM staffing levels are maintained and providing training for new and existing staff in a consistent format to ensure the integrity of the UM and CM Programs. Supports staff satisfaction and retention through education, training, recognition, leadership, and provision of resources required to do each job effectively.
Provides ongoing education for staff regarding utilization management theory and processes, the requirements of AHCCCS/HCGA , and organizational policy. Develops inter- and intra-departmental systems and monitors utilization processes to comply with all aspects of contracts with regulatory and non-regulatory agencies regulations to ensure continued viability of all Health Plan products. Develops policies and procedures and assures such policies are consistent with the requirements of AHCCCS and HCGA as well as other selected regulatory agencies, and applicable contracts. Assures compliance with state and federal regulation.
Acts as the clinical liaison with State HCGA and AHCCCS for the UAHN Utilization Management and Case Management programs. Provides vision and clinical operations leadership to UM staff in the delivery of UM programs. Provides vision and clinical operations leadership to CM staff in the delivery of CM programs. Supervises and manages the utilization and case management functions to include referral processing, concurrent hospital review, discharge planning, medical claims review, denials, admissions, case management and transitions. Operates with high integrity and principles. Creates a positive environment where staffare motivated to do their best work. Demonstrates high respect for others in all interactions and drives expectations for respect for the team.
Bachelors degree in Nursing is required.
Requires a current licensure as a Registered Nurse in the State of Arizona.
Requires five to seven years of director level experience in health care management, and prior experience in progressively responsible roles in health care management, including utilization management is required. Experience in a case, utilization, or quality management leadership role is preferred. Experience with development and implementation of benchmarks, metrics, and measurements.Must have knowledge of quality improvement processes. Must have knowledge of the requirements of national/state accrediting agencies, such as NCQA, HEDIS, Medicare (CMS) and Medicaid (AHCCCS). Must be able to demonstrate successful experience and program development/improvement in medical management programs, including concurrent review and case management. Excellent communication skills are required, as are analytical, problem solving and computer skills and the ability to create, manipulate and manage databases. Must possess the ability to prepare and deliver presentations that summarize, analyze, and interpret data and make recommendations for courses of action for program and operational changes. Must possess the ability to lead, work collaboratively with, and implement plans with multi-disciplinary teams. Must possess the ability to establish strong working relationships and work collaboratively with key internal and external stakeholders, including staff, peers, medical directors, providers, AHCCCS and other health system leaders.
Masters degree in Business, Healthcare, or a related field is preferred.
Additional related education and/or experience preferred.
You want to change the health care industry – one life at a time. You belong here. You’re excited to be part of the dramatic changes happening in the health care field. In fact, you thrive on change. But you also understand that excellent, compassionate patient care is the true measure of the success of these changes. You belong at Banner Health. Our award-winning, comprehensive health system includes 23 hospitals in seven western states, primary care health centers, research centers, labs, a network of physician practices and much more. Throughout our system, skilled, compassionate professionals use the latest technology to change the way care is provided. If you’re looking to be a key contributor to a forward-looking organization, you’ll experience a wide variety of professional advantages: •Our vision for changing the future of health care gives you the opportunity to leverage your abilities to achieve something historic. •Our expansive system offers you an unmatched variety of clinical settings – from large urban trauma center to small rural hospital, ambulatory to home health. Our system also includes hospitals specializing in cancer, heart health and pediatrics. •Our many loc...ations also translate into a broad selection of exciting and rewarding lifestyle options – from the big city to the wide-open spaces. •Our commitment to healthcare innovation means you always have the latest technologies at your fingertips to help you provide the finest care possible. •The size, success and growth of our system provide you with the stability and options to pursue your desired career path. •Our competitive compensation and comprehensive benefits offer you options to complement your unique needs.