The Manager, Medical Management supervises and leads the Utilization and Case Management Departments, including planning, organizing, and coordinating the activities of the Utilization Management and Case Management programs. Requirements include demonstrating mastery of the managed care environment, TRICARE, DoD, Utilization Management and Case Management standards and programs, and USFHP Policies and Procedures. Ability to develop and manage within budgetary guidelines. This position includes daily clinical discretionary capacity that has potential to affect the financial well-being of the health plan.
Responsible for all management aspects of the Medical Management department (Case Management/Utilization Management), including:
Manage and supervise the selection, training, development, appraisal, and work assignments, staffing and productivity of Associates within Medical Management.
Responsible for daily operations of the Medical Management Department.
Responsible for all reporting and report preparation functions within the Medical Management Department, including quarterly reports to the CQI Committee and Department of Defense
Is responsible for ongoing compliance with existing Contractual and regulatory standards within the Medical Management Department.
Ensures application of existing review criteria in the Utilization Review Process.
Is responsible for monthly submission of cases to the TQMC
Is responsible for the bi-annual NCI Clinical Trials reports
Responsible for ongoing evaluation and improvement of work processes, within department to ensure optimum potential of the department and Associates
Participates in the development, implementation, and evaluation of Care Management Programs as part of annual strategic initiatives and reporting.
Supervises daily activities of Care Management clinical staff, individually and as a team to ensure the following objectives are met:
Accountable for Associate Satisfaction within Utilization Management Department
Accountable for Member Satisfaction related to the Case Management Department
Active liaison to Medical Director, Hospitalists, Network and Non-Network Providers (Institutional and Individual)
Active participant in Management Staff meetings
Participates in work groups and committees oriented toward improving health plan operations
Routinely reviews reports related to area of responsibility and provides feedback with regards to opportunities for improvement and related plans of action
Responsible for development and maintenance of policies and procedures for department.
Responsible for HIPAA and Integrity compliance within department
Responsible for ensuring staff compliance with URAC requirements
Assist in the development of the departmental budget
Conduct monthly staff meetings
Complete evaluations of direct reports
Works closely with department Director to identify and plan for opportunities for improvement within areas of responsibility
Follow the CHRISTUS Guidelines related to the Health Insurance Portability and Accountability Act (HIPAA), designed to prevent or detect unauthorized disclosure of Protected Health Information (PHI)
Communication, Collaboration and Coordination with all customers, internal and external
Collaborate with and maintain open communication with all departments within CHRISTUS Health and US Family Health Plan to ensure effective and efficient workflow
Assumes responsibility for professional development by attending educational seminars and or participating in written educational initiatives and CHRISTUS Management Courses
Tracks applicable laws and regulations and ensures compliance.
Graduate of an accredited Registered Nursing program
BSN , required.
Master's degree, preferred.
Strong computer skills required
Experience with Clinical Decision Support tools (i.e.: InterQual, MCG, etc...)
Experience with word processing/spreadsheets including Excel.
Excellent verbal and written skills
Experience with audits and regulatory agencies mandatory.
Minimum of five to seven years clinical experience
Minimum three years management experience
Minimum three years Health Plan experience
Three to five years Utilization Management/Case Management experience
B. Licenses, Registrations, or Certifications:
Current/Active Unencumbered Texas RN licensure
Eligibility for Louisiana RN licensure (obtained within 6 months of employment)
CHRISTUS HEALTH is an international Catholic, faith-based, not-for-profit health system comprised of almost more than 600 services and facilities, including more than 60 hospitals and long-term care facilities, 350 clinics and outpatient centers, and dozens of other health ministries and ventures. CHRISTUS operates in 6 U.S. states, Colombia, Chile and 6 states in Mexico. To support our health care ministry, CHRISTUS Health employs approximately 45,000 Associates and has more than 15,000 physicians on medical staffs who provide care and support for patients. CHRISTUS Health is listed among the top ten largest Catholic health systems in the United States.