Director, Care Management

What We Provide

• Referral bonus opportunities

• Generous paid time off (PTO), starting at 30 days of paid time off and 9 company holidays

• Health insurance plan for you and your loved ones, Medical, Dental, Vision, Life and Disability

• Employer-matched 401k retirement saving program and opportunity for both pre- and post-tax contributions

• Personal and financial wellness programs

• Pre-tax flexible spending accounts (FSAs) for healthcare and dependent careand commuter transit program

• Generous tuition reimbursement for qualifying degrees

• Opportunities for professional growth, career advancementand CEU credits

What You Will Do

• Partners with VNS Health Plans leadership in the development and implementation of care management strategic plans, goals and objectives aligned with the Health Plan and VNS Health's overall strategic goals. Executes strategic plans to achieve goals and financial targets to support the growth and profitability of the plan.

• Evaluates effectiveness of care management operations and utilization management using benchmark and objective data, including member health outcomes, satisfaction survey results (CAHPS), utilization metrics, and HEDIS star ratings.

• Identifies, monitors, and evaluates key performance indicators, trends and needs of members and member services; develops strategies to address areas of opportunity to improve.

• Collaborates with quality department to set quality goals and establish methods and tools for staff audits, evaluation, and assessments. Monitors overall results, identifies trends, reports on findings, and makes recommendations for improvements.

• Ensures that care management activities and operations are in compliance with federal, state, and local health care regulations and standards of accrediting organizations; oversees the periodic review and audit to ensure compliance with program policies, state, and federal regulations.

• Collaborates with health plan leadership and marketing department to support the development of marketing plans. Participates in outreach activities to promote plan growth. Increases public awareness of the program through education, presentations, publications, and marketing activities.

• Oversees multi system integrity, upgrades, customization and reporting to ensure departmental efficiencies and regulatory compliance.

• Provides oversight of care management- functions delegated to vendors including review of entities' policies and procedures and member health outcomes. Identifies areas of concern and coordinates with Vendor Delegation in development of corrective action plans, as appropriate.

• Develops and supports relationships with providers that result in continued improvement in quality healthcare outcomes. Drives efforts to engage providers in collaborative efforts during care transitions.

Licenses and Certifications:

• License and current registration to practice as a Registered Professional Nurse in New York State or Licensed Social Worker preferred

Education:

• Bachelor's Degree in Nursing, Social Work, a related field, or the equivalent work experience required

• Master's Degree preferred

Work Experience:

• Minimum eight years of clinical nursing or health care experience, including a minimum of two years in a managed care/HMO organization required

• Minimum two years managerial experience over a managed care medical management system required

• Experience with State and external accreditation managed care audits and reviews required

• Experience with Health Plan Employer Data and Information Set (HEDIS), Consumer Assessment of Healthcare Providers and Systems (CAHPS), and Health Outcome Surveys (HOS) required

• Experience with Quality Assessment and Process Improvement (QAPI) projects required

• Experience with writing and implementing program level policy and procedures required

• Proficient with computer and software programs (e.g.; Microsoft Word, Excel) and the Internet required

• Experience applying medical management treatment guidelines, such as InterQual / McKesson, Milliman, or other practical management guidelines required