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Job Posting

Director Health Care Management RN

Company: AMERIGROUP Maryland, Inc.

Location

Job Description:

The Director, Health Care Management Services is responsible for the development, implementation and coordination of a comprehensive health care program that will assist Health Care Management Services, Medical Management, and/or Health Plans, resulting in improved health outcomes for members.

PRIMARY RESPONSIBILITIES:
1. Assists in development and implementation of clinical programs (case management) in accordance with the goals of AMERIGROUP Corporation’s mission, vision and values, the needs of the health plans, federal and state regulatory requirements and NCQA standards.

2. Serves as a clinical leader to HCMS / Medical Management associates.

3. Manages and evaluates team’s performance and ensures adherence to department’s standards.

4. Provides departments with updates as needed to ensure continued compliance with specific medical management standards

5. Assists in the development of medical management policy, procedures and guidelines that relate to specific programs.

6. Assists in evaluating and implementing contracts in coordination with Network Development as needed to implement specific programs.

7. Assists Member Services and Provider Inquiry Department with timely response to issues including complaint resolution.

8. Assists in developing clinical management guidelines including:
• Conducting literature search to identify “evidenced-based” management
• Identifying changes in practice which may require updating of guidelines
• Developing DRAFT guidelines as directed
• Identifying national providers experienced in treating patients within these areas
• Coordinating physician advisory groups

9. Assists in managing the information requirements of HCMS / Medical Management programs.

10. Acquires data and evaluates necessary medical, mental health and substance abuse services for cost containment.

11. Identification and implementation of HCMS/ Medical Management “best practices.”

12. Ensures that delegated medical management activities are contracted, reviewed and reported according to established criteria.

13. Evaluates programs quarterly.

14. Supports and participates in quality initiatives and activities including clinical indicators reporting, focus studies and HEDIS reporting.

15. Ensures compliance with state reporting on utilization management activities for accuracy.

16. May assist in developing the annual operating and capital budgets to sufficiently meet departmental needs.

17. Other duties as requested or assigned.

EDUCATION AND EXPERIENCE:
Education
Required: Bachelors Degree, or equivalent work experience
Preferred: MSN, MPH, MPA, or MSW or related or MBA with Health Care Concentration

Years and Type of Experience
Required:
• Must have five years management experience.
• Must have at least five years of current experience in utilization management in a managed care setting.

Knowledge and Technical Skills
Required:
• Demonstrated medical management experience in health care.
• Knowledge of Utilization Management targets
• Self-directed with strong organizational skills.
• Excellent verbal and written communication skills.
• Ability to foster inter and intradepartmental communication and team building.
• Strong analytical capabilities.
• Attention to detail.
• Mastery of computer software.
• Statistical reporting experience preferred.
• Multi-task oriented with ability to follow-up on numerous complex problems.
• Strong customer focus.

Certifications or Licensure
Required: RN or LCSW , LPC
Preferred: Certified Case Manager

SCOPE INFORMATION
Item Measure
• # Direct Reports 2-10 (or individual contributor in a coaching/training capacity within the department)
• # Indirect Reports 2-20
• Budgetary $ Responsibility As assigned

PHYSICAL REQUIREMENTS
• Able to operate a computer
• Able to operate a telephone
• Must be able to travel on common carriers and to adhere to AMERIGROUP’s travel policies.

In accordance with state and federal laws, employment offers are tendered solely on the basis of qualifications without regard to race, religion, color, national origin, age, sex, marital status, sexual orientation, handicap (including disabled veterans) or Vietnam Era veteran status.

AMERIGROUP administers pre-employment drug testing as a condition of employment and a satisfactory criminal history background report.

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