• Provides clinical and operational oversight of each Health Services initiative which includes Case Management and the analysis of clinical data to drive performance improvement.
• Reviews and revises Case Management Program Description annually or as indicated by contract or accreditation requirements.
• Conducts annual evaluation of Case Management programs per contract or regulatory requirements.
• Identifies, assesses, develops, and implements cross-functional, cross-departmental work processes that impact various departments or the company to improve clinical outcomes.
• Identifies opportunities to improve clinical care, customer service and internal business processes.
• Represents Medical Management for Medicaid Special Programs, including Foster Care and Medallion Care System Partnership (MCSP).
• Ensures assessment, planning, implementation, tracking, monitoring, coordination, reconciliation and evaluation of Embedded Care Management programs in a variety of settings.
• Collects, reports, trends, and analyzes Care Management program elements for departmental productivity and performance outcome reporting.
• Validates Care Management quality audit results for accuracy and individual developmental needs.
• Develops, implements, and monitors policies and procedures for contract and accreditation compliance.

MINIMUM EDUCATION REQUIRED

• Minimum education degree of Bachelors of Science in a health care field
• License – Current Registered Nurse licensed to practice nursing in Virginia;
• Certified Case Manager (CCM) preferred
• Master’s degree preferred

SPECIAL KNOWLEDGE AND/OR SKILLS

• Highly motivated individual with the ability to work independently as well as part of a team
• Excellent verbal and written communication skills
• Knowledge of NCQA and HEDIS
• Knowledge of Medicaid and Medicare programs
• Demonstrated knowledge of Care Management principles
• Strong analytical problem-solving, time management, and organizational skills
• Proficient Microsoft Office product computer skills
• Proficient in Six Sigma or other performance improvement methodology
• Ability to travel frequently to various VPHP locations throughout Virginia
• Knowledge in program start-up and/or enhancements                                                                                       

WORK BACKGROUND/EXPERIENCE

• Minimum of 5 years of case management experience preferably in a managed care setting
• Minimum of 5 years of management experience
• Knowledge of utilization management, preferably service authorizations related to waiver services
• Minimum of 2 years of experience in Medicaid and Medicare managed care

PHYSICAL REQUIREMENTS

• Physical health sufficient to meet the ergonomic standards and demands of the position.
• Regular local & state travel will be required