Director, Care Management

Gold Coast Health Plan will not sponsor applicants for work visas.

The pay range above represents the minimum and maximum rate for this position in California. Factors that may be used to determine where newly hired employees will be placed in the pay range include the employee specific skills and qualifications, relevant years of experience and comparison to other employees already in this role. Most often, a newly hired employee will be placed below the midpoint of the range. Salary range will vary for remote positions outside of California and future increases will be based on the pay band for the city and state you reside in.

POSITION SUMMARY

Under administrative direction of the Executive Director Health Services, the Director, Care Management is responsible for overseeing all aspects of the care management program, including complex care management, care coordination and transitions of care. Working in conjunction with the GCHP Chief Medical Officer (CMO) and the Executive Director Health services, the Director, Care Management designs, implements, and executes on CM strategic directions and leads a variety of professional and support staff to ensure members navigate health plan benefits and services efficiently and effectively. Maintains policies and procedures to meet strategic goals and ensures regulatory/contractual compliance. Actively engages at a leadership level to manage regulatory medical audits and inquiries. Assists quality improvement initiatives by implementing processes to improve member outcomes. Coordinates relationships with clinical and social service agencies; provides leadership support to both internal and external advisory groups and clinical committees; participates in the grievance process and system as needed; and performs other duties as assigned.

Distinguishing Characteristics: This classification is distinguished from other director-level classifications in that it deals directly and proactively with client needs and manages a large staff of professional nurses, licensed clinical social workers, and support staff. Advises and collaborates with the Executive Director Health Services and Chief Medical Officer on strategic issues involving CM programs.

Amount of Travel Required: 10-20%

Work Schedule: Travel; protracted and irregular hours and evening meetings or work unusual hours for meeting attendance or participation in specific projects or programs.

ESSENTIAL FUNCTIONS

Reasonable Accommodations Statement

To accomplish this job successfully, an individual must be able to perform, with or without reasonable accommodation, each essential function satisfactorily. Reasonable accommodations may be made to help enable qualified individuals with disabilities to perform the essential functions.

Essential Functions Statements

* Direct and oversee all Care Management programs including strategic planning, policy development and program implementation. Collaborate with senior leadership, including Executive Director, Health Services and Chief Medical Officer, to align care management programs with organization goals. Direct and oversee the integration of DSNP and Medi-Cal care management programs into regulatory compliant care delivery model.

* Lead team in the development, implementation, and improvement of care management and transition of care programs. Ensure programs meet strategic goals and regulatory requirements.

* Develops, collaborates for, and maintains policies and procedures to meet goals and ensuring regulatory/contractual compliance, collaborating in managing regulatory audits and inquiries.

* Directs CM activities to assist the quality improvement programs, including, but not limited to, quality measure gap closure programs and member grievance and appeals processes aimed at improving health outcomes for Medi-Cal and DNSP eligible populations.

* Acts as a leadership liaison and coordinates working relationships with community based clinical and social service agencies, and documenting protocols for agency communications and referrals.

* Supervise, train, and evaluate a diverse team of clinical and support staff. Manage performance, provide leadership support, and ensure team goals align with organizational objectives.

* Prepares for, attends, and/or leads a variety of meetings to assist with Plan programs.

* Independently develops and designs strategies to comply with regulatory mandates involving direct member interface for improvement of health outcomes

* Collaboratively leads internal stakeholders in member-facing communication efforts

POSITION QUALIFICATIONS

Competency Statements

* Leadership - Ability to influence others to perform their jobs effectively and to be responsible for making decisions.

* Applied Learning - Ability to participate in needed learning activities in a way that makes the most of the learning experience.

* Communication, Oral - Ability to communicate effectively with others using the spoken word.

* Communication, Written - Ability to communicate in writing clearly and concisely.

* Customer Oriented - Ability to take care of the customers' needs while following company procedures.

* Team Builder - Ability to convince a group of people to work toward a goal.

* Commitment to Diversity, Equity and Including to ensure effective CM team development and impactful interactions with members, providers and key stakeholders.

SKILLS & ABILITIES

Education:

* Bachelor's Degree (four-year college) Required, Field of Study: Clinical Health Care such as Nursing (RN), Behavioral Health (LCSW/LMFT/BCBA), Therapy (PT/OT/ST/Nutrition).

* Master's Degree Preferred, Field of Study: Nursing (MSN), Social Work, Family Marriage Therapy, Health/Hospital/Business Administration, Public Health.

Experience:

* 8+ years of experience in medical or behavioral health care management.

* 8+ years of supervisory or management experience in a health care area.

* Expert knowledge of Managed Care and Care Management programs.

* Previous experience working with Government programs, including both Medi-Cal and Medicare.

* Computer Skills: Advanced computer skills included in MS Office products.

Certifications & Licenses:

* Current and unrestricted State of California RN license.

* Utilization Management/Case Management certification preferred.

* Possession of, or ability to obtain, a valid appropriate California driver's license. Maintain a satisfactory driving record.

Other Requirements:

* Ability to build, lead and influence diverse teams across the organization to achieve Program goals.

* Strong communication skills, verbally and in writing.

* Strong data analysis skills.