ESSENTIAL DUTIES AND RESPONSIBILITIES  

• Supports the activities and goals of the Medical Director.
• Participates, provides input and impacts on outcomes of the following; Medical Management Committee, Population Health Management Task Force, Internal committees and other committees as assigned.  May need to attend off site meetings.
• Responsible for data collection, planning, reporting, and implementing success initiatives with each line of business, including but not limited to Overall Health Care Cost PMPM; Quality of Care Metrics as it relates to Population Health Management; Acute patient care episodes through admits, readmits, ER visits, and referrals.
• Coordinates all activities and policy development related to contractual, state and federal regulatory requirements.
• Directs, plans, and supervises activities for Utilization Management, Case Management and Quality Health Specialist staff teams in an efficient and effective manner utilizing time management skills to facilitate the total work process.  Provides constructive information to minimize problems and increase customer satisfaction.  Spends time with each area to mentor, foster working relationships and provide education needs.
• Provides effective problem solving, serves as a liaison and resource with internal and external customers to provide optimal customer satisfaction.
•  Maintains current knowledge of health plan benefits and provider networks.  Guides internal and external providers on preferred providers and facilities.
• Participates in the development, planning and execution of continuous quality improvement (CQI) efforts, policies and procedures, and regulatory compliance functions related to Quality Health Management Department activities. Develops initiatives for process improvement for the Quality Health Management Department.
• Develops new policies, procedures, job aids, and work flows that enhance operating efficiency of the care management program or activities;
• Evaluates the success of process improvement efforts and implements solutions for growth opportunities.
• Evaluates care management staff performance by performing, at a minimum, one on one individual meeting every other month.  Provide coaching for performance success.  In coordination with HR consistently execute disciplinary actions/Performance Improvement Plans.
• Interviews, hires and retains quality staff to meet the business needs.
• Ensures the timely preparation of reports and records for dissemination to appropriate stakeholders.
• Completes and/or provides input on budget.
• Will need to be able to walk or drive to various meetings on time.
• Must be able to cognitively function at a high level.
• Has familiarity with components of a Magnet environment and is supportive of all initiatives within the structure.

EDUCATION & EXPERIENCE  

• Bachelor of Science in Nursing required
• 5 + years of varied clinical experience
• 5+ years of experience in the managed care, disease/utilization management, case management with a minimum of three years at the management level or above
• 2+ years of experience with Epic/ Tapestry Referral program. 
• Broad Knowledge of federal and state laws relating to health care and insurance companies in MercyCare service areas.
• Experience in NCQA regulation relating to managed care, disease management, utilization management, transition planning and complex case management
• Knowledge of basic principles and practices of clinical nursing
• Broad Knowledge of referral processes, claims, case management and physician practices as related to Insurance Industry.
• Knowledge of fiscal management and human resource management techniques
• Excellent written and verbal communication skills
• Extremely proficient with computer software programs including Microsoft Office, to include spreadsheets and  graphics, databases

Preferred Qualifications

• Masters degree in nursing, healthcare administration or business administration
• 10+ years of experience in managed care and/or population health management with a minimum of five years at a management level
• Epic/Tapestry Certifications          

CERTIFICATION/LICENSURE                    

• Registered Nurse with license in Wisconsin and Illinois and/or ability to obtain licensure in these states.
• Commission for Case Management Certification as a Certified Case Manager (CCM) or American Case Management Association (ACMA) as an Accredited Case Manager (ACM) or American Association of Managed Care Nurses as a Certified Managed Care Nurse (CMCN) or meets the requirements to become certified within 6 months of hire.