Director of Medical Management

Directs the daily activities of the Medical Management Department, including utilization review, concurrent review, authorizations, discharge planning, case management, and disease management.

Essential Functions:
- Directs the operations of the health plan’s utilization management programs, including prior authorization, concurrent review and discharge planning. Responsible for other health plan medical services, including medical case management, the integration of disease management, and coordination of behavioral health services in plans where behavioral health is managed. These responsibilities cover all locations where plans are managed by SAH.
- Prepares an annual Utilization Management Plan and Annual Evaluation of Utilization Management activities.
- Monitors and evaluates continuously the efficiency and effectiveness of the Plan's utilization management activities through analysis and the use of relevant data and management reports.
- Organizes and develops the agenda for the Utilization Management committee and various internal departmental committees
- Supervises and mentors supervisor of case and disease management, reporting analysts, and medical management staff of plans without a supervisor. Also serves as a resource for issues and initiatives relating to these functional areas.
- Works with managers in departments of other SA organizations where responsibility for certain plan functions are delegated such as prior authorization, concurrent review, etc to ensure operations are being performed to SAH standards.
- Works with medical directors in the development, implementation and evaluation of Plan medical and utilization management policy.
- Participates in corporate medical management meetings, programs, and projects such as disease management, inter-rater reliability, etc. and maintains responsibility for communicating and executing throughout medical management staff.
- Keeps abreast of local medical trends, analyzes patterns that impact the effort to effectively manage utilization and quality of medical services, and reports these in 30/60/90 process.
- Prepares the medical management section used in client reporting performed monthly, quarterly, and annually.
- Develops projected budget requirements and monitors expenditures for medical management.
- Facilitates ongoing training for managers, supervisors and staff.
- Ensures sufficient resources are available for completion of required departmental tasks
- Works with the Chief Medical Officer to develop innovative approaches to improve cost effectiveness and reduce administrative expenses.
- Works with the Chief Medical Officer to develop innovative approaches to improve program development and implementation.
- Coordinates with quality initiatives.
- Works with Chief Medical Officer to develop and update medical management policies and promote understanding of policies among medical management employees.
- Ensures compliance with Plan Sponsor and regulatory requirements for all lines of business, including assuming a leadership role in any external quality review activities (e.g. Operational and Financial Review)
- Develops and maintains communication within the medical management department which allows the Director to have an awareness of daily operational activities, i.e. regular one on one staff meetings with direct reports, quarterly staff meetings, etc.
- Assists with implementation of health plans for new clients.
- Participates in various health plan committees.
- Maintains confidentiality of information.

Secondary Functions:
- Assists where needed with pharmacy management.
- Maintains professionalism and excellent customer service orientation, including strict observance of all privacy and confidentiality rules.
- Works in a manner that is not disruptive to peers, supervisors and/or subordinates.
- Maintains regular and acceptable attendance at such level as is determined in the employer’s sole discretion.
- Maintains availability and willingness to work such days and hours as the employer determines are necessary or desirable to meet its business needs.
- Maintains availability and willingness to travel to such locations and with such frequency as the employer determines is necessary or desirable to meet its business needs (if travel required).
- Conducts timely performance evaluations and makes recommendations about compensation
- Acts as a resource to all departments regarding medical management.
- Assure orientation and staff development requirements are met.
- Assists with other duties and special projects as assigned.Knowledge and Skills:
Incumbent must have skills in management, supervision, program development and implementation, advanced problem solving and organizational skills. Effective and advanced oral and written communication skills and the ability to prioritize multiple tasks are necessary. Knowledge of commercial health plan management is necessary. General understanding of NCQA standards, and Federal Health Care regulations. The ability to establish and maintain a constructive relationship with diverse members, management, employees, and vendors. The ability to use advanced reasoning to define problems, collect data, establish facts, draw valid conclusions, and design, implement and manage appropriate resolution are required. Requires strong problem solving, organizational, and time management skills and ability to work in a fast paced environment. Proficiency with Microsoft Office Suite applications and common computer and office hardware is necessary. Additionally, incumbent must be able to use specific software essential to the business such as claims information program, case and disease management programs, etc. Incumbent must be able to counsel, plan and train, while managing various staffing patterns.

Education and Work Experience:
Five years of progressively responsible health care administrative experience, with a minimum of two years in commercial managed care environment. Masters degree in nursing or BSN with extensive administrative experience preferred, although not required.

Work Environment Qualifications:
Position is a computer station, office environment. Incumbent may be required to sit for extended periods and must generate written work using computer/keyboard. Incumbent will have one on one contact with other employees in a environment where hearing and listening are paramount. Participation in various meetings is required. This position is required to work efficiently under significant time and deadline pressures. Position is supervisory and functional role; therefore, incumbent must possess comprehension, perception, and negotiation abilities and must be able to delegate responsibilities where appropriate. Incumbent is expected to use diplomacy and problem- solving skills to procure data and information from other sources as well as handle incoming inquiries. Occasional requirements are: to stand, walk, use hands to manipulate, handle or feel objects, tools, or controls, reach with hands and arms, stoop, kneel, and lift/move up to 25 pounds. Incumbent may be expected to travel to meet business needs.

Positions Reporting:
- Manager, Case Management