Director, Government Care Management
PacificSource

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PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, national origin, sex, sexual orientation, gender identity or age.

Diversity and Inclusion: PacificSource values the diversity of the people we hire and serve. We are committed to creating a diverse environment and fostering a workplace in which individual differences are appreciated, respected and responded to in ways that fully develop and utilize each person's talents and strengths.

Position Overview: The Director of Government Care Management is responsible for leading, developing, and operationalizing care management/care coordination within the population health strategy for our Medicare (HMO, PPO) and Medicaid (5 CCO Regions). Provide oversight to ensure the company's government-related care management and contractual performance objectives are met, programs and resources are used effectively and successful execution of both short- and long-term population health goals. Reports to the Senior Director of Care Management.

The Director of Care Management Government works within and across a matrixed environment to develop and lead a proactive and evolving care management strategy, incorporating performance improvement, regulatory adherence, accreditation, and Dual Eligible Special Needs Plan (D-SNP) Model of Care (MOC) compliance. This position involves significant collaboration with the leadership of internal and external stakeholders (e.g. Quality, Compliance, Pharmacy, Utilization Management, Population Health, Line of Business Leaders) and other identified stakeholders to address all aspects of CM. Performance improvement efforts cover a variety of processes, and the Director of CM Government must be sufficiently knowledgeable to recognize important synergies and opportunities in clinical outcomes, cost containment, and member experience.

Essential Responsibilities:

• Responsible for leading organization-wide Care Management (CM) initiatives, programs, plans, and policies in accordance with strategic business objectives, professional standards, and applicable regulatory requirements.
  
• Accountable for oversight and compliance CM role in the D-SNP Model of Care (MOC), including:
  
  • Monitoring, oversight, and quality assurance of D-SNP CM reporting and audit universes.
    
  • Developing and monitoring key process and performance metrics to ensure high-quality, compliant operations and product performance.
    
  • Enhanced coordination between Medicare and Medicaid with leaders of other clinical programs (e.g. quality, pharmacy, utilization management and transitions of care) to ensure member needs are met.
    
• Champion member centered care as a philosophical approach to inform Care Management strategies and programs. Champion motivational interviewing as the foundation of our overall Care Management program.
  
• Lead a culture of innovation to advance new CM models and processes that better serve members and their families, with the goal of reducing medical spend and enhancing quality metrics/outcomes.
  
• Liaison between IT, Analytics, and HS leaders to support the population health management platform to ensure regulatory compliance, scalability and reporting needs are met.
  
• Accountable for CM collaboration and alignment with clinical quality initiatives (NCQA, CMS Stars, OHA QIM), performance, improvement programs as needed.
  
• Promote best practice recommendations, evidence-based standards, and regulatory requirements to ensure adherence to CMS, NCQA, Oregon Health Authority.
  
• Perform employee management responsibilities to include but not limited to hiring and termination decisions, coaching and development, rewards and recognition, performance management, and staff productivity.
  
• Ability to interpret/explain complex data, information and outcome measures to key stakeholders including senior leadership and executive management.
  
• Accountable for the development and monitoring of department budgets and monitoring budget vs. actual throughout the year.
  
• Accountable for continuous process improvement utilizing lean methodologies, visual boards and daily huddles to monitor key performance indicators and identify improvement opportunities.
  
• Superior problem-solving skills, including the ability to identify issues, analyze data and resolve in an effective and timely manner.
  
• Responsible for ensuring CM support for Request for Proposals (Medicare/Medicaid)
  
• Lead efforts advance the integration of physical, behavioral, and oral health programs into the CM model.
  
• Collaborates with Medical Directors and Regional Care Teams to address member care needs.
  

Supporting Responsibilities:

• Serve on designated committees, teams, and task groups, as directed.
  
• Work with Medical Directors in responding to inquiries or complaints and pertinent report preparation for other review functions.
  
• Work collaboratively with the UM Director to ensure seamless care transitions across the care continuum and to establish best practice strategies for managing members across LOB's.
  
• Participate in and support project teams led by other departments and provide necessary input to support the goals of colleagues.
  
• Meet department and company performance and attendance expectations.
  
• Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
  
• Perform other duties as assigned.
  

SUCCESS PROFILE

Work Experience: At least seven (7) years of experience with varied medical exposure required. Minimum of 3 years management or supervisory experience required. Knowledge and experience with Medicaid and Medicare clinical operations in health plans including medical management platforms is required. Experience in case management, disease management, utilization management and program development using evidence-based medicine required. Prior success in healthcare integration, process development and program implementation is desirable. Additional experience managing complex work processes, including D-SNP, Medicaid, Medicare, Quality Programs (CMS Stars, OHA, NCQA) preferred.

Education, Certificates, Licenses: Clinical Bachelor's degree required. Registered nurse or behavioral health clinician with current unrestricted state license preferred. Master's degree strongly preferred. Certified Case Manager Certification (CCM) as accredited by CCMC (The Commission for Case Management) strongly desired at time of hire. CCM certification required within two years of hire.

Knowledge: Knowledge and understanding of disease prevention, medical procedures, diagnoses, care modalities, procedure codes (including ICD-10, CPT, and HCPCS codes) health insurance, and state mandated benefits. Knowledge/experience with quality improvement initiatives in the clinic setting including clinical quality outcomes and patient experience. Knowledge and experience with NCQA accreditation, HEDIS measures, Medicare Star Ratings, and Dual Eligible Special Needs Plans required. Thorough knowledge on coordinating community, provider, and vendor services available to to assist members. Must have strong analytical skills and business acumen to interpret strategic vision into an operational model. Ability to lead with high motivation and strong interpersonal & communication skills (oral and written). Proficiency in computer skills using Word, PowerPoint, and Excel. Experience giving presentations. Ability to work independently with minimal supervision. Ability to effectively engage with members, patients and families at all levels of care and/or crisis.

Competencies

• Authenticity
  
• Building Organizational Talent
  
• Coaching and Developing Others
  
• Compelling Communication
  
• Customer Focus
  
• Empowerment/Delegation
  
• Emotional Intelligence
  
• Leading Change
  
• Managing Conflict
  
• Operational Decision Making
  
• Passion for Results
  

Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 30% of the time.

Our Values

We live and breathe our values. In fact, our culture is driven by these seven core values which guide us in how we do business:

• We are committed to doing the right thing.
• We are one team working toward a common goal.
• We are each responsible for customer service.
• We practice open communication at all levels of the company to foster individual, team and company growth.
• We actively participate in efforts to improve our many communities-internally and externally.
• We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community.
• We encourage creativity, innovation, and the pursuit of excellence.

Physical Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.

Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.

This job has expired.