Senior Director Care Management San Antonio TX

    • San Antonio, TX

Position Description

Do you have compassion and a passion to help others? Transforming healthcare and millions of lives as a result starts with the values you embrace and the passion you bring to achieve your life's best work.(sm)

We are now seeking an experienced Senior Director of Care Management in San Antonio, TX. The Senior Director of Care Management is responsible for planning, organizing, and directing the ancillary support for the Utilization Management team. The Senior Director is responsible for operational oversight and team coverage for the Intake, Prior Authorization , Correspondence, and the Medical Claims Review teams, to ensure compliance with regulatory, contractual and accreditation requirements. Role is responsible for the planning and growth of the department to meet current and future needs of the organization. The success of this position requires the ability to foster communication and teamwork among physicians, medical management staff, corporate departments, vendors, and senior leadership.

Primary Responsibilities:

  • Sets organizational priorities for the team and defines approach and effort for team direction.
  • Plans, develops and implements policy and procedure for current and future workflows within the related UM areas to meet agreed organizational performance plans and expansion within agreed budgets and timeframes (relevant areas of operation include those noted above).
  • Manages departmental functions, workflows, policies and procedures to ensure that all Federal and State regulations and contractual agreements are followed. Ensures all applicable employee and other training programs for the department staff to ensure that regulatory compliance requirements are disseminated and understood.
  • Oversees the management of staffing ratios of all UM personnel, the assignment of duties, the supervision of the effectiveness of the UM program related to staff, within the structure of the budget for the department.
  • Drives the implementation of processes and system enhancements which will improve the overall quality and service provided by the UM teams.
  • Establishes and maintains appropriate systems and scorecards for measuring necessary aspects of operational management and development.
  • Analyzes trends and implements departmental initiatives based upon data provided through the reporting of production, quality, financial and audit data.
  • Using feedback from customers and work partners, forecasts future needs in relation to growth and/or new services and plans for growing the department capabilities over a significant period of time.
  • Maintains a personal level of professionalism through attendance at required meetings and evaluating problematic issues using all resources for resolution. These interactions should cultivate relationships with medical groups and primary care physicians for customer development and knowledge sharing. Oversees the recruiting, performance, development and mentoring of Prior Authorization, Correspondence, Hospital Intake and Medical Claims Review staff.
  • Encourages, initiates, and participates in cross functional/departmental discussions and initiatives to remove barriers and improve communications and work flows.
  • Collaborates with senior level business, medical and IT leaders on company-wide initiatives related to medical costs, revenue, payment integrity, encounter submissions/responses/reconciliation, payer partner strategy, and UM initiatives.
  • Motivates and guides management staff cascading healthy management practices and positive culture to employees. Key to effectiveness of the Senior Director is the ability to motivate and coach management team members in their development as effective managers of people.
  • Leads and directs the management of the annual departmental budget, in coordination with the VP of Utilization Management
  • Maintain communication with the VP of Utilization Management with routine updates on operation updates, issues, concerns and other pertinent information.
  • Performs all other related duties as assigned.

You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

  • Bachelor's Degree in Nursing, Business Administration, Health Care Administration or related field
  • Active, unrestricted Texas license, with ability to obtain license in other states as necessary
  • 5 years' experience in Medical Management operations
  • At least five years of experience at a manager level or above capacity in a managed care organization
  • Demonstrated knowledge of regulatory and accrediting standards relating to medical management and managed care
  • Demonstrated knowledge of medical terminology and claims processing
  • Demonstrated knowledge of fiscal management and human resource management techniques
  • Proficiency with Microsoft Office applications to include intermediate Excel skills

Preferred Qualifications:
  • Master's degree
  • Ability to plan, supervise and review the work of non-clinical and clinical staff
  • Requires working under stressful conditions or working irregular hours
  • Creative problem-solving and communication skills
  • Able to work effectively and achieve results in a real time, fast paced environment
  • Analytical skills with strong organization skills
  • Eight to ten years experience in managed care with a minimum of five years at a management level working in a call center environment

Careers with WellMed. Our focus is simple. We're innovators in preventative health care, striving to change the face of health care for seniors. We're impacting 380,000+ lives, primarily Medicare eligible seniors in Texas and Florida, through primary and multi-specialty clinics, and contracted medical management services. We've joined Optum, part of the UnitedHealth Group family of companies, and our mission is to help the sick become well and to help patients understand and control their health in a lifelong effort at wellness. Our providers and staff are selected for their dedication and focus on preventative, proactive care. For you, that means one incredible team and a singular opportunity to do your life's best work.(sm)

Diversity creates a healthier atmosphere: OptumCare is an Equal Employment Opportunity/Affirmative Action employers and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.

keywords: RN, registered nurse, care management , um, director, leader, san Antonio, tx, manager, compliance

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