Director of Case Management
4 weeks ago
Arizona Priority Care (AZPC) is an Integrated Provider Network focused on providing Whole-Person care to Senior and Medicaid populations, through advanced value-based models. Our provider network is comprised of more than 4,000 providers including Primary Care, Specialty, Hospital System and ancillary provider partnerships. We have operated in the Arizona market for more than 12 years, and are based in Chandler, Arizona. As a leading value-based provider organization, we are committed to improving the quality of care, providing excellent member and provider experiences all while reducing cost.
The Director of Case Management is responsible for oversight, mentoring and evaluating with clinical staff within the Care Management Department.
Position Duties & Responsibilities
- Contribute to annual budget goals and encourage staff to reduce departmental costs.
- Establishes objectives and evaluate criteria for department, including TCM, CCM, Hospital/SNF Care Management, and specifies strategies to ensure success of these programs. Will ensure ongoing development, training, implementation and innovation of these programs.
- Develop and implement innovative strategies to improve care, so as to reduce admissions and ED visits.
- Works effectively and collaboratively with contracted partners and providers to improve patient care, ongoing communication, and decreasing frequency of emergency department visits and hospital admission/readmission, while maintaining high quality continuity of care.
- Change management – demonstrated ability, and preferable experience, in securing buy-in for new initiatives within Clinical Services team.
- Develop new strategies, and implement them to assure maximum engagement of beneficiaries, for interventions provided by AZPC.
- Identifies and prioritizes member needs based on clinical evaluations, while working with the multi-disciplinary teams to problem-solve, promote quality of care with cost effective outcomes and communicates findings to the appropriate person or department.
- Uses clinical judgement to triage the needs of PCP’s requesting case management and determines appropriate interventions.
- Communicates routinely with medical directors and apprises them of any inpatient/outpatient activity requiring immediate intervention.
- Develops, revises and implements department P&P’s, standard operating procedures (SOP’s) for identification, collection and analysis of performance measurement data, to continually improve department services, operations and reporting.
- Coordinates the appropriate documentation to assist with outpatient prior authorizations generated from inpatient hospitalizations, as part of discharge plan.
- Will annually review corporate UM Programs, as well as corporate P&P’s, and assist with modification to accurately reflect AZPC operations.
- Assists with investigation process of grievances, appeals and potential quality issues.
- Assists with developing instructional materials and conducts necessary training within department, ensuring maintenance of proof of training.
- Maintain awareness of advances in health care, government regulations, health plan changes, and member coverage options.
- Participates in annual health plan audit preparation and coordination, as requested.
- Will participate in QIC/UMC meetings, as requested.
- Responsible for annual evaluations of staff performance and ongoing mentoring.
- Responsible for reviewing Job applications and interviewing/hiring prospective team members.
- Oversees new hires orientation & training process in order for staff to perform at the expected level.
- Establishes and maintains effective internal and external professional relationships to facilitate a system-focused structure.
- Maintain a strong teamwork philosophy and willingness to accept change proactively.
- Other duties or special projects as assigned.
Education, Training and Experience
- Current, unrestricted AZ Registered Nurse license required.
- Bachelor’s degree in nursing or other health care field required; Master’s degree preferred.
- Minimum of 10 years acute hospital experience, with most recent year preferably in ER or ICU or other relevant clinical role requiring quick critical thinking experience required; 5 years’ experience in a managed care setting, directly related to care management functions, and experience with NCQA UM accreditation process.
- 5 years supervisory experience with advanced leadership skills required.
- Technical skills: Intermediate to Expert level Microsoft Excel, Word, PowerPoint, Outlook, NextGen, EZCAP, qHMO.
- Self-motivated with advanced assessment, analytical and problem-solving skills with ability to multi-task in a fast-paced environment with changing priorities is required, including ability to work independently.
- Exceptional organizational and project management skills including strong attention to detail and accuracy.
- Exceptional interpersonal, verbal and written communication skills, including proofreading and grammar skills.
- Must have the ability to train and present information accurately and communicate effectively with all levels of internal staff and external customers in a professional manner.
- Must have the ability to present clinical information both accurately and confidently.
- Able to communicate effectively and in a professional manner with all levels of internal staff and external customers.
- Driving occasionally required. Current and unrestricted AZ driver license with proof of insurance required.
- *This role requires FT in-office presence for the first 60 days of employment. Hybrid schedule available after initial training period.*
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