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Managed Care Vice President, Care Management/Utilization Management
at HSC Health Care System
Washington, DC

Managed Care Vice President, Care Management/Utilization Management
at HSC Health Care System
Washington, DC

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Description

Job Description

JOB SUMMARY

The VP, Care Management/Utilization Management is responsible for oversight and management of the health plan's Clinical Operations Team including Utilization Management and Care Management in accordance with HSCSNs CASSIP contract. This position works collaboratively with the Chief Medical Officer to develop and implement processes to effectively manage clinical policies to meet healthcare cost, quality targets, and implements a program of care coordination and utilization management as defined in the CASSIP contract. Oversees the provision of a range of services and benefits in accordance with the CASSIP contract from multiple network providers. Goal of coordinating covered health care services with other community services available in the District of Columbia including educational, social, disability services. Promotes linkage between utilization management, care coordination and quality improvement activities. Acts as a role model for clinical staff, promoting education, development and adoption of the CQI process. Promotes teamwork, and works independently, while maintaining appropriate communication with CMO and Senior Leadership.

JOB FUNCTIONS

Essential job duties:

  1. Works with the Clinical Operations Team to achieve successful implementation of HSCSN clinical strategy and direction.
  2. Develops and implements effective and efficient standards, protocols, processes, decision support systems, reporting and benchmarks that support ongoing improvements of clinical operations functions and promote quality cost effective health care for HSCSN members.
  3. Monitors and evaluates key care coordination processes and practices to ensure achievement of the organizations mission and goals and improve health outcomes of members.
  4. Mentors, guides and develops skills of clinical team members in a consistent and effective manner.
  5. Develops initiatives to achieve increases in quality scores.
  6. Develops departmental budgets and ensures budget targets are met.
  7. Manages implementation of analytical studies that quantify the benefits of CASSIP programs to ensure that resources are appropriately allocated, operational controls exist, and efficiencies are maximized.
  8. Facilitates integration of care coordination with CASSIP program partners Child & Family Services Administration (CFSA), Department of Youth Rehabilitation Services (DYRS), Department of Behavioral Health (DBH), Office of the State Superintendent of Education (OSSE) and Katie Beckett.
  9. Continually refines operational processes and champions review of team processes, workflows and activities.
  10. Articulates project requirements and anticipated outcomes to the senior management team and board for identified projects/strategies to improve the efficiency of clinical operations teams to meet cost and quality goals.
  11. Accountable for ensuring compliance with contractual, accreditation and regulatory requirements for Care Management and Utilization Management teams.
  12. Participates personally or assigns appropriate staff to Quality Committees and external Community Committees to represent the clinical departments.
  13. Ensures effective inter-departmental collaboration and interaction between clinical staff and other departments.
  14. Ensures that monthly auditing of clinical staff is performed and appropriate actions and/or coaching occur.
  15. Responsible for oversight of clinical training activities and outcomes.
  16. Responsible for clinical related delegation oversight monitoring
  17. Develops and maintains a positive working relationship on behalf of HSCSN with the District of Columbia Office of Medical Assistance Administration.
  18. Works with IT staff to define care management systems requirement, which meet regulatory and analytic needs.

QUALIFICATIONS:

Required Experience:

Previous experience in supervising and performing utilization management and care management functions, preferably in MCO setting. At least five years management experience in utilization management or case management with sound clinical background.

License/Certifications:

Certified Case Manager or equivalent credential preferred.

Required Education:

Advanced degree in business or health care administration required.

DC Residents are encouraged to apply!

Company Description

The HSC Health Care System provides and coordinates innovative, high quality, community-based care for individuals with complex needs and their families. HSC empowers all we serve to improve the quality of their lives.

The HSC Health Care System (HSC) is a nonprofit health care organization committed to serving families and adults with special health care needs and eliminating barriers to health care services. The System combines the resources of a health plan (Health Services for Children with Special Needs, Inc.), pediatric specialty hospital (The HSC Pediatric Center), home health agencies (HSC Home Care, LLC and HSC Health and Rehabilitative Services), and parent foundation (The HSC Foundation) to offer a comprehensive approach to caring, serving and empowering people with disabilities.

HSC employs over 700 staff members, with operating revenue of approximately $225 million annually. Strategic plans include further expansion of services into broader territories, including Virginia. As a first-of-its-kind health system in Washington, DC with more than a century of experience, The HSC Health Care System remains committed to changing the lives of the people we serve through expert medical care, care coordination and advocacy. Today, we are known for our expertise in treating children, teens and adults who have disabilities and complex medical conditions.

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