RN Director of Case Management - TPA

Location: Lancaster, PA
Date Posted: 02-01-2018
RN Director of Case Management - Managed Care
Lancaster, PA
Your Job Summary:
The Director of Case Management provides clinical leadership for all Care Management and Disease Management programs by serving as an educator, role model, member advocate, and change agent to enhance member care and staff competency.  They also ensure that departments maintain compliance with corporate, state, and federal regulations. The Director collaborates with other departments, to evaluate and coordinate activities and programs in support of delivery of patient care.  They create and implement case and disease management programs that keep up with the changing environment of healthcare management.  The Director oversees daily team operations and provides strong leadership through training, coaching, teaching, and managing assigned teams and departments.
Your Reward:
Work with an exceptional organization focused exclusively on promoting the health care and quality of life for its members.  The forward-looking health plan has a demonstrated passion for finding innovative ways to enhance member’s ability to manage their own health.
Your Background
Valid, unrestricted state Registered Nurse (R.N.) license and BSN; Master's degree preferred.
Around 3-5 years Case Management experience; Certified Case Manager (CCM) is required.
At least 4-5 years clinical nursing experience at an acute care hospital or other provider setting.
At least 2-3 years managerial experience and leadership of a Case Management staff, ideally within a managed care (Health Plan/HMO/IPA/TPA) environment.  
Prefer 5 or more years of complex case management experience, ideally with a mix of provider and health plan settings.
Familiar with Utilization Management processes, data analytics, and population health initiatives.
Experience with the creation and implementation of new or unique clinical programs is highly desired.
Ability to analyze and integrate information and make sound decisions based upon established guidelines.
Resourcefulness as demonstrated by the effective application of professional knowledge to new situations. Possess planning, organizing, conflict resolution, negotiating and interpersonal skills.
Experience in training / teaching staffs to meet operational requirements and goals.
Strong oral and written communication skills; ability to interact with all levels of internal and external contacts.
Must be able to prioritize, plan, and handle multiple tasks/demands simultaneously.
Your Duties:
Provides clinical guidance and supervision to all case management programs, based on accepted principles of nursing, social work, gerontology, geriatrics and case management practice.  Provides clinical perspective and best practices to staff through one-on-one coaching, group interaction at IDTs, in-service training, and other team meetings. 
Manages a staff of nurses and administrators, and monitors department activities to evaluate the productivity and quality of programs and processes in order to identify potential improvements and to ensure maximum performance.  Develops, manages and participates in departmental projects, workflow processes, policies and procedures in collaboration with internal and external stakeholders.  Ensures availability of specialized expertise to HCS programs by identifying case management needs and identifying and training subject matter experts.  Develops and maintains professional networks and individual relationships with hospitals, physicians, and other providers in order to promote continuity and quality of care.  Collaborates with staff and leadership to develop and implement systems that support operations and business goals within identified areas of responsibility.  Maintains professional and clinical relationships with Medical Directors, AMDs, UM Director, and the Director of Healthcare Delivery; regularly discussing any concerns regarding utilization of services or complicated cases.  Uses a collaborative approach with the case management team in order to revise, develop, and implement cost savings methodologies and interventions.  Facilitates communication with providers to ensure continuity of care and coordination between multiple specialists, providers, and vendors.   Enhances clinical quality of networked medical groups and their attendance to SNP requirements by training medical group staffs upon request. 
Recommends and participates in departmental policy and procedure development; and participates in internal and external committee meetings, such as the Quality Assurance Committee and the Joint Operating Committee.  Acts as a resource and provides expert clinical opinions to all areas within the organization.  The Director will ensure that policies and procedures are developed and enforced in alignment with the standards of patient care and regulatory bodies and that the core components of the case management process are followed.
Erik Berg
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