Director of Utilization and Case Management

  • Aids Healthcare Foundation
  • Fort Lauderdale, FL , United States
  • Jan 05, 2018
Full time Case Manager Nurse

Job Description

The Director of Utilization and Case Management is accountable for the Managed Care Division’s Florida based clinical program operations, including Managed Care Chronic Case Management, Utilization Management, Waiver programs and Ryan White Medical Case Management.

Duties and Responsibilities include but are not limited to:
  • Collaborates with all managed care departments and AHF functions to develop and maintain Managed Care clinical programs, including the Chronic Care Model, which is the basis for the Case Management Program..
  • Works closely with management and staff to facilitate adherence to Plan operational standards and regulations.
  • Responsible for Project Management related to clinical programs, including specific regulatory required processes and program enhancements.
  • Assures timely reporting of required data through the Quality Management Committees and contracted private and/or governmental agencies and the Board of Directors,  including the annual UM Program Description, Workplan and annual UM Program Summary.
  • Ensures there is appropriate monitoring of staff and department outcomes relative to performance objectives, including individual and collective feedback to the clinical team.
  • Demonstrates comprehensive knowledge of Agency for Health Care Administration (AHCA), and Medicare (CMS) Medicare Advantage and Part D regulations as they pertain to managed care clinical operations.
  • Collaborates with all managed care departments to ensure operational effectiveness of the Clinical Programs.
  • Establishes measureable performance goals for staff and department programs including, UM, CM, MTMP, Ryan White and Waiver Medical Case Management Programs.
  • Is an active participant in the preparation and execution of the Utilization Management Committee.
  • Regularly attends and participates in the bi-weekly FL Operations meeting
  • Reports UM/CM Department performance and outcomes to appropriate committees.
  • Collaborates and cooperates with the Compliance Officer to ensure programmatic compliance to regulatory guidance in assigned areas.
  • Assists with development of the operational budget and allocation of resources.
  • Participates in Contracting and Provider Relations activities as necessary to develop and maintain provider networks based on member need.
  • Ensures the appropriate authorization and appeals processes per regulatory requirements. 
  • Collaborates with the Medical Director to ensure the Clinical appropriateness of programs and process.
Management Responsibilities
  • Demonstrates the ability to organize and facilitate effective meetings.
  • Develops project plans, coordinates projects and communicates project outcomes
  • Responsible for hiring, training and motivating staff
  • Mentors and develops the Manager of UM/CM, case managers, and others, as needed, on the team
  • Disciplines in conjunction with Human Resources and AHF guidelines
  • Addresses concerns and resolves issues
Participates in AHF Meetings/Committees
Attends AHF and Managed Care Committees including:
  • Quality Management Committee,
  • Pharmacy and Therapeutics
  • Utilization Management Committee
  • Member Provider Committee
  • Medical Staff Committee
To perform this job successfully, an individual must be able to satisfactorily perform the essential duties.  The requirements listed below are representative of the knowledge, skill, and/or ability required.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and/or Experience
•    Graduate from an accredited RN program 
•    Current, unrestricted FL RN license
•    BS in Nursing or other healthcare field
•    Masters Degree preferred or demonstrated comparable managerial and executive experience
•    Minimum of five years experience in managed care with emphasis in Medicaid and Medicare.

Computer/Software Skills & Abilities
To perform this job successfully, an individual should have knowledge of standard business software, including but not limited to: word processing, spreadsheet software, presentation software, experience with relational database principles and functions, and a basic understanding of claims administration principles is required.

Language Skills
Ability to read, analyze, and interpret the most complex documents. Ability to respond effectively to the most sensitive inquiries or issues.  Ability to effectively present information to top management or public groups.

Mathematical Skills
High mathematical skills required. Ability to apply mathematical principles to practical solutions, using fractions, percentages, ratios, and proportions.

Reasoning Ability
Ability to define problems, collect data, establish facts, and draw valid conclusions.  

Travel locally and in the domestic United States up to 40% of the time

Other Skills & Abilities/Qualifications
Ability to successfully work with various levels of professional and non-professional staff.
Must be able to work independently and as a part of a team.
Knowledge of HIV/AIDS, related medical and patient care issues and concerns in diverse populations.

Certificates, Licenses and Registrations
Current unrestricted FL RN License required
CCM preferred