Senior Manager Medical Expense Management

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Responsible for coordinating care management activities and clinical program development. Provides coordination of the overall activities of care management department. Leads the development of care management objectives, policies, plans, programs and budgets while maintaining a cost efficient and effective service, supporting the organization's clinical practices.

Primary Responsibilities:

• Oversees Utilization and Referral programs, including acute care, skilled nursing facility and home care, achieving targeted outcomes
• Integrates utilization and referral management groups. Organizes to maximize program efficiency and effectiveness. Recruits and oversees team leaders. Oversees evaluation of the clinical performance of the department and staff. Oversees the day-to-day operations of all utilization and referral management programs
• Manages identification of pending high cost cases
• Responsible for compliance to and meeting all NCQA requirements for delegated case management as well as being responsible for NCQA certification for utilization management
• Responsible for the successful implementation of all future, delegation efforts
• Manages expenditures such as utilization: inpatient, SNF, hospital outpatient expenses: ER, facility, home care, ambulance, DME, tertiary referrals and POM with Service Director, regional leadership and others, participate in clinical program development, implementation, business plans, trade-off proposals
• Manages inpatient and outpatient populations to anticipate needs, optimize outcomes and cost-effective care. Implements and monitors programs focused on proactive outreach for high-risk patients
• Ensures quality of department services via ongoing training of staff, case review, internal audits and inter-rater reliability audits
• Interfaces and resolves issues with vendors such home health care, hospitals, nursing facilities, etc., to ensure appropriate quality of care and service is delivered to patients. Participates in research activities to establish benchmarks; stay informed about innovative programs that can be replicated at the organization
• Recruits and selects members of the utilization and referral management teams to manage the needs of assigned areas of responsibility
• Delegates authority and responsibility to members of the teams for the operation and coordination of the programs and services
• Works with department leaders to minimize outside referrals and resolve identified barriers to care
• Acts as a resource for team members as needed
• Manages the business and fiscal affairs of the department, including the preparation of business plans and annual capital and operating funds budgets. Monitor and assume corrective action for variances
• Establishes positive working relationships with the organization's site staff as well as payer staffs and management
• Directs and supervises assigned personnel including performance evaluations, scheduling, orientation, and training. Makes recommendations on employee hire, transfers, promotions, salary changes, discipline, terminations, and other similar actions. Resolves grievances and other personnel problems within position responsibilities
• Develops and recommends, in conjunction with manager, the operating and capital budgets for the areas managed. Manages activities to assure financial goals met. Monitors expenditures for compliance to approved budget. Resolves discrepancies
• Coordinates the assignment of tasks and helps resolve technical and operational problems. Evaluates the impact of solutions to ensure goals are achieved
• Provides effective direction, guidance, and leadership over the staff for effective teamwork and motivation, and fosters the effective integration of efforts with clinic-wide initiatives
• Participates in performance improvement initiatives and recommends procedural changes when appropriate
• Ensures compliance with regulatory agencies such as DPH, etc. Develops…