"Alerted.org

Company :

Endorsed

Job Description :

JOB SUMMARY

This job is a strategic leadership role responsible for the development, implementation, and oversight of comprehensive care management programs and services within designated service line. This position requires a sophisticated understanding of care management principles, operational efficiency, financial performance, and regulatory compliance. The Director will lead and develop high-performing teams, ensuring the delivery of high-quality, cost-effective care that improves member outcomes and enhances satisfaction. The successful candidate will possess strong clinical expertise, analytical skills, and demonstrated experience in building and maintaining effective relationships with internal and external stakeholders.

ESSENTIAL RESPONSIBILITIES

+ **Leadership & Management:** Perform management responsibilities to include, but are not limited to: involved in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity.Plan, organize, staff, direct and control the day-to-day operations of the department; develop and implement policies and programs as necessary; may have budgetary responsibility and authority.

+ **Strategic Planning and Program Development:** Develop and implement strategic and operational plans, including budget development and management, for designated service line, aligning with organizational goals and market trends. This includes forecasting future needs, identifying new program opportunities, and ensuring that programs remain relevant and competitive in a dynamic healthcare market. Continuously monitor and adapt the plans based on performance, regulatory changes, and emerging best practices.

+ **Operational Management & Process Improvement:** Oversee the day-to-day operations of the care management team(s), ensuring effective resource allocation and efficient service delivery. Implement robust quality control systems and processes. Actively identify and lead process improvement initiatives focused on quality, utilization, cost containment, and enhanced member clinical outcomes. Leverage data analysis to support decisions.

+ **Clinical Program Oversight and Quality Assurance:** Ensure the delivery of high-quality clinical care management programs, including disease management, health coaching, care coordination, and member outreach. Monitor and maintain compliance with clinical guidelines, quality metrics, best practices, and all applicable regulatory requirements (CMS, URAC, NCQA, etc.). Oversee the implementation of innovative disease management and preventative health programs.

+ **Stakeholder Management:** Cultivate and maintain effective relationships with internal and external stakeholders, including physicians, hospitals, community organizations, regulatory bodies, sales, and market leadership, to optimize collaboration and efficient care delivery.

+ **Performance Measurement & Reporting:** Develop and monitor Key Performance Indicators (KPIs) to assess program effectiveness. Regularly report on program progress, including clinical, financial, and operational outcomes to leadership. Utilize predictive modeling to proactively identify at-risk members and improve engagement strategies.

+ **Regulatory Compliance:** Maintain compliance with all applicable federal, state, and local regulations, including CMS, URAC, NCQA, and other relevant standards.

+ Other duties as assigned or requested.

EXPERIENCE

Required

+ 7 years of experience in a healthcare setting

+ 5 years of experience in Management or leadership role directly related to case or disease management

+ 3 years of experience working with diverse populations and care delivery models

Preferred

+ 5 years of experience in the designated service line (DSNP, Medicare, or Medicaid)

SKILLS

+ Demonstrated strategic planning, operational management, and leadership abilities

+ Strong analytical skills

+ Proven ability to manage budgets, personnel, and resources effectively

+ Exceptional communication and interpersonal skills

+ Deep understanding of healthcare regulatory environments, and quality metrics

+ Ability to develop and implement effective program evaluations and reporting systems

+ Proficiency with performance improvement methodologies

EDUCATION

Required

+ Bachelor’s degree in Nursing, Business Administration, Healthcare Administration, or a related field or relevant experience and/or education as determined by the company in lieu of bachelor's degree.

Preferred

+ Master's degree in Nursing, Business Administration, Healthcare Administration, or a related field

LICENSES or CERTIFICATIONS

Required

+ None

Preferred

+ Registered Nurse (RN) or Licensed Social Worker (LSW)

+ Case Management Society of America (CMSA) certification or other relevant disease management certification

Language (Other than English):

+ None

Travel Required:

+ Less than 25%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type (enter from JDQ)

+ Office-Based or Remote Position

Physical work site required

+ None

**_Disclaimer:_** _The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job._

**_Compliance Requirement_** _: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies._

_As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy._

_Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements._

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.

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Req ID: J270322