Director Clinical Services – Case Management
Job Description
Los Angeles, California – Hybrid
Salary $170,000/yr – $200,000/yr
The Director of Case Management ensures compliance with specific DMHC, DHCS, CMS, NCQA, and health plan requirements in the areas of Case Management, Care Coordination and Transition of Care (collectively referred to as CM or Case Management). The Director oversees, creates, maintains and implements the CM Program, Work Plans, Policies and Procedures as well as comprehensive compliance activities and interventions for Case Management functions. Works collaboratively with the Sr. Directors and Vice Presidents to assure Case Management requirements are fully integrated into the medical group delegation oversight and monitoring, health plan compliance/oversight, quality and analytic functions. Assures proactive internal quality monitoring and a state of constant readiness to meet regulatory and accrediting requirements.
The Director is accountable to act as a liaison and advisor to the CM business owners within affiliated medical groups to enable groups to develop and maintain compliant processes, record keeping and reporting. The Director is also responsible for maintaining relationships with all contracted health plans’ delegation oversight and/or CM points of contact. Work is complex and requires a high degree of independent judgment, emotional intelligence, and personal initiative.
A. Essential Duties and Responsibilities include the following:
1. Leading the health plan Case Management function, the Director works collaboratively with Medical Group CM and UM leaders to ensure:
a. Accurate case management health plan reporting
b. Accurate reporting of CM data
c. Successful CM health plan audits
d. Clear understanding of delegated CM responsibilities
2. Provides guidance and expertise to Medical Group CM leaders including but not limited to:
a. Response to and closure of Corrective Action Plans
b. Regulatory and accreditation requirements
c. Health plan delegated responsibilities
d. Achievement of Regulatory, Health Plan and performance standards.
e. Operational effectiveness and efficiency.
3. In conjunction with leadership, implements strategies and processes to assure ongoing
readiness and compliance with DMHC and NCQA CM requirements. Leads efforts to achieve and maintain NCQA CM accreditation.
4. Provides expertise and input in the development, review and updating of Policies and Procedures for CM functions.
Qualifications:
1. Graduate from an accredited school for Nursing.
2. Unrestricted Active California Registered Nursing License.
3. CCM Certification required.
4. Minimum five (5) years leadership experience at the Director level or above; minimum three
years in Case Management.
5. Minimum five years (5) minimum of Case Management experience at a Health plan or delegated
group/IPA.
6. Five to Seven (5-7) years of clinical experience preferred.
7. Demonstrated knowledge of regulatory requirements including DMHC, DHCS, CMS and NCQA
requirements.
8. Proficient in MS Office programs (i.e., Word, Excel, Outlook, Access, and Power Point).
9. Typing 60 words per minutes with accuracy.
10. Ability to deal with responsibility with confidential matters.
11. Able to manage and prioritize multiple projects simultaneously
12. Must have strong analytical, creative problem solving, and organizational skills.
13. Ability to strategize effectively, execute within timelines, and deliver quality results
14. Must have the ability to work with all levels of management and have the ability to develop
positive working relationships across the company.