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Director Health Management

KVR Consultant
Portland, Maine, United States
December 02, 2016

Posted By Premium Recruiter


Position Summary:

This position serves as the leader for all clinical operations within the Health Management Department. The Director has primary responsibility to carry out all care coordination services including those described in the Program Description. Accountabilities include all clinical operations, processes, programs, policies, procedures, documentation and reporting. Additionally, the Director participates with the Vice President of Health Management, Health Plan Medical Director, and other leaders throughout to develop programs that support the success of all components of the Triple Aim. Care coordination activities include but are not limited to: health promotion and prevention, pre-admission planning, utilization management, discharge planning, transitions of care, case management, disease management and condition specific programs. Additionally, the Health Management Division provides expert clinical review of complex claims, reconsiderations and benefit interpretation issues or questions. This key leadership position works collaboratively with several other departments across the organization.

Key Outcomes and Primary Accountabilities:

Ensure tactical implementation of the Care Coordination Program through and by:

Modeling behaviors consistent with leadership attributes

Staying apprised of industry best practices in all operational areas of the department

Using LEAN leadership and process principles to build and maintain standard work, drive continuous improvement, manage through metrics, and ensure goal achievement

Providing a personal example of professional practice, demonstrating excellence in the care coordination process, including identification, engagement, assessment, care planning, intervention and evaluation.

Maintaining focus on the improvement of health outcomes through strategy and collaboration.

Leading care coordination activities to reduce the cost per capita for all member populations

Maintaining an extensive understanding of reimbursement models, utilization patterns and quality improvement opportunities.

Proposing and planning new programs and services to meet population health needs, client expectations, and marketing strategies and to manage medical costs.

Articulating the vision for the department and motivating staff to strive for that vision and ensuring the department’s goals and strategies align with the organization’s vision and strategy

Collaborating with other departments and divisions to integrate health care financing and delivery, creating measureable health care value

Participating in external professional organizations and committees

Oversee the operations of the department by:

Developing annual department specific goals and objectives goals, quality management plans and the department budget.

Overseeing all project plans, action plans and budgets to ensure goals are met

Establishing consolidated management reports to monitor the progress and outcomes of all care coordination activities carried out by the department.

Developing, implementing and ensuring continuous quality improvement and process re-engineering to deliver effective and efficient programs and services

Ensuring all programs are documented through policies, workflows and manuals

Ensuring adequate technology solutions and data management to support operational functions and to optimize efficiency

Managing the relationships and coordination with external vendors and providers (e.g. health coaching, disease management, third party administrators, etc.)

Collaborate with Director of Quality to support quality initiatives including HEDIS, Member Safety, QIPs, and others and providing data and information to identify ongoing quality initiatives.

Provide oversight, support and mentoring to department staff by:

Setting and communicating department goals and expectations

Promoting professional development of the entire department through, coaching, talent management, and training.

Managing performance issues in a timely and constructive manner

Participating in Health Plan and Organizational Committees and Work Groups as needed

Ensure department compliance with professional and regulatory Standards, federal contracts, and accreditation standards.


Minimum of 8+ years of health care experience with 4+ years of leadership experience in a managed care setting, preferably in commercial and Medicare Advantage Plans

Experience overseeing utilization management, case management and disease management required

Bachelor’s degree in nursing with Master’s degree in nursing or related field strongly preferred

Experience using data and data analysis to design programs, manage care coordination services and measure success strongly preferred

Experience managing external relationships with vendors, clients and physician partners strongly preferred

Experience with health program strategy, design, implementation and evaluation preferred

Experience applying CMSA, URAC and NCQA standards as well as State and Federal regulations preferred

Skills/Knowledge/Competencies (Behaviors):

Strategic ability to see the big picture and lead a team through change towards a vision

Demonstrated ability to proactively develop and implement new programs or services based on data and benchmark analysis

Strong project management experience and the ability to operationalize a concept

Proven ability to establish department work plans, goals and manage to those objectives

An effective team builder and leader with a track record of integrating functions and fostering a positive work environment that motivates staff to achieve their potential

Strong track record of building internal and external collaborative relationships

Demonstrated ability to develop proactive and innovative solutions to improve process effectiveness

Demonstrated ability and desire to coach employees and develop staff through training, stretch assignments and constructive feedback

Broad understanding of medical management and population health management programs as well as how these programs operate most effectively.

High level understanding of health information systems including care management support systems and informatics used to plan, design and evaluate impacts of programs