To be fully engaged in providing Quality/No Harm, Customer Experience, and Stewardship by:
developing, implementing and monitoring the Case Management structure and systems at Health First Health Plans. To promote operational effectiveness while ensuring the provision of appropriate reimbursable care. Responsible for Case Management (including both Complex and Acute/Catastrophic) and Disease Management at the Health Plans. Oversees the implementation and standardization of best practices throughout the Case Management department at the Health Plans and team building that maximizes efficiencies and talents. The Director Case Management at the Health Plans shall possess comprehensive knowledge of the healthcare industry, familiarity with regulatory and accreditation agencies, strategic planning skills and an understanding of the operations of hospitals and healthcare organizations.
Will direct departmental activities to provide comprehensive case coverage at the Health Plans.
Serves as an expert in fields and Case Management and managed care, interpreting and communicating processes.
Will work diligently to increasingly engage, provide tools of engagement, and raise issues of engagement with direct reports.
Directs the development of job descriptions and performance standards for all Case Management services at the Health Plans.
Provides ongoing coaching and staff development to ensure performance of team members.
Evaluates and provide feedback to staff on their performance.
Achieve Gallup scores in accordance with corporate goals.
Oversees the development, training and education of staff.
Demonstrate leadership and industry expertise by collaboration and communication with other health plans and hospital constituents to improve internal departmental processes and methodologies.
Serves as a professional role model while supporting and exhibiting the Organization’s mission, vision and values in all departmental activities.
Promotes associate accountability and competency through leadership and management practice.
Interviews, evaluates and selects new personnel for the Case Management department at the Health Plans.
Completes performance appraisals and competency check list for personnel on an annual basis and as necessary in a timely manner.
Committed to a safe work environment 100% of the time.
Promotes patient/member safety through leadership and oversight of staff to ensure patient/member obtains the best quality care available.
Supports EMR/Admission and prior authorization review, utilization management, and concurrent and retrospective review processes.
Develops policies, procedures, and standards for the department and are reviewed and revised annually or as needed.
Cultivates Case Management team’s interaction with Physician Advisory Council (PAC) to foster Optimal patient outcomes.
Oversees the standards and guidelines to ensure that all available resources are identified for care managed patients.
Oversees transition and discharge planning of all patients at the Health Plans.
Establishes corporate objectives and performance standards for the Case Management Department. Assures accountability of Case Management staff at the Health Plans.
Directs the quality and performance improvement activities of Case Management and Utilization Management based on interpretation and analysis of data.
Ensures Case Management team at the Health Plans is compliant with all regulatory and accreditation agency standards. Prepares for site visits and responds to accrediting and regulatory agency inquires and audit requests (not limited to CMS, NCQA).
Facilitates Case Management involvement in establishing, implementing, coordinating, modifying, and optimizing a collaborative, appropriate and member/patient focused plan of care while ensuring clinical, customer/patient satisfaction and achieving financial goals.
Develops innovative methods of directing and measuring department operations, utilizing advanced technologies and maintaining efficiency of process and staff productivity.
Assists with Case Management departmental operations to include: budget preparation, operations monitoring, assignment scheduling, quality improvement initiatives and departmental audits.
Facilitates, enhances and develops professional working relationship between all Health First departments, hospital facilities, physicians and other community health service providers.
Participates in developing and maintaining positive relationships with all providers and vendors.
Ensures processes are in accordance with contracts and policies.
Ensure that Case Management staff is identifying and making referrals to other Health First Health Plan programs to include: Case Management, Care Management, and Disease Management.
Direct quality and efficient member care coordination to ensure an optimal member/patient experience and maximize customer satisfaction.
Mediates and assists with complex problem solving, conflict resolution, and prioritizes continuous improvement principles.
Utilizes team building and leadership skills to resolve interpersonal conflict and obtain staff commitment to new ideas and changes in service processes.
Continuously develop innovative strategies to manage utilization and medical expenses at the Health Plans.
Oversight of the NCQA certified Complex Case process for timely and accurate evaluation of patient/member status to ensure established medical necessity met that drives reimbursement.
Works closely with facility COOs, VP Medical Affairs, Physician Advisors, and Patient Business Services to enforce clinical and financial program components and optimize the case management strategies, goals and productivity standards.
Development of relationships with third party payers and community providers of ancillary services to promote coordination of care and improve quality outcomes.
Designs and implements programs to support cost containment, productivity, and other financial matters.
Controls departmental cost through economical utilization of personnel, materials and equipment.
Collaboration with all SNF, LTAC, In-patient facilities, etc., to ensure appropriate reimbursement of services rendered at the Health Plans. Repatriation effort oversight.
Develops, implements and monitors departmental plan to include identification and allocation of appropriate resources, cost containment measures and departmental projects.
Plans, develops, implements, and monitors all financial management activities including but not limited to budgeting and staffing under the direction of the Vice President of Clinical Operations.
Current Florida RN license or MSW required.
Bachelor’s Degree from an accredited College or University required, Master’s Degree in appropriate healthcare area preferred.
*Certification in Case Management (CCM) preferred.
Maintains professional competency by attending managed care seminars, conferences, etc.
Minimum of five years of combination of hospital based clinical nursing experience/Utilization management/Quality Management/Managed care experience with minimum of 3 years’ progressive administrative experience.
Knowledge of CPT Codes, HIPAA, ICD-9/ICD-10 Codes, Medicare/Medicaid Guidelines, Joint
Commission and other regulatory/accreditation agencies.
Knowledge of Coordination of Benefits where applicable. (i.e., Worker’s Compensation, Auto Insurance, Short and Long Term Disability).
Knowledge of Billing and Claims Processing.
Knowledge of alternative treatment options, alternative funding programs and community services and resources.
Demonstrated skills in leading and facilitating work efforts.
Strong analytical, communication and problem-solving skills.
Ability to conduct meetings and speak in front of large groups.
Health First is Central Florida's only fully integrated health system. With a mission to positively change the health and wellness of the communities we serve, Health First offers the latest technological advances and quality care at our four hospitals and through our many Outpatient & Wellness Services, as well as the area's only Trauma and Heart Centers. Health First also offers multiple commerc...ial and Medicare health plans, the largest multi-specialty physician group in Brevard County, and four fitness centers to help members of our community stay healthy.