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Job Description

Job Summary

Develops comprehensive plans for managing the health care costs of members through development and implementation of effective and efficient standards, protocols and processes, reports and benchmarks that further enhance the case and utilization management function. Directly oversees case and disease management and medical utilization operations for assigned area(s) targeting at risk populations and coordinates effective delivery of care to improve quality of life and directly impacting medical cost ratio. Assures state and federal regulatory compliance applicable to medical operations.

Essential Functions

• Responsible for planning and executing the medical management programs and strategies that will ensure clinical excellence and fiscal soundness. Analyzes data to identify significant trends; develops measurable standards to monitor and evaluate quality, cost and effective use of case management resources.
• Leads the development of well-planned, well-integrated, cost effective approaches to the medical management of members. Ensures proactive intervention and targeted use of case management resources. Coordinate care effectively among all providers to ensure a seamless delivery system.
• Plans, organizes, implements and directs case management operations with all stakeholders, internally and externally. Collaborates with medical and business leadership to drive programmatic initiatives and evaluate program success. Utilizes data and predictive intelligence to ensure programs are appropriately designed from concept through to implementation.
• Incorporates evidence based best practice standards into program development. Researches, analyzes and defines programs; develops the structure and key elements of the program; manages the development of new programs from concept to implementation; provides post-implantation monitoring and oversight.
• Assures that measurable outcomes are in place to monitor the impact of programs and services on the health and financial status of members. Identifies variations in care and promotes provider accountability to clinical outcomes and financial prudence. Influences the quality delivery of care with all key stakeholders while eliminating waste and duplication.
• Ensures that staff receive appropriate orientation, training and ongoing professional development to meet the needs to the population served. Ensures all team members are educated and competent on all medical conditions that are managed.
• Develops and implements training modules for case and disease management operations. Ensures assessments and other tools are evidence based.

Qualifications

• Bachelor's Degree Nursing or allied health - Required
• Preferred Master's Degree MBA, Nursing, or related field

• 7 years of relevant experience clinical leadership experience in a health services setting (hospital, doctor’s office or health plan). Required
• 5 years of relevant experience managed care and/or case management experience Preferred
• Experience in Medicare and Medicaid - Preferred

• LIC-Registered Nurse (RN) - STATE_MI State of Michigan Upon Hire required Or
• LIC-Master Social Worker (MSW-Master) - STATE_MI State of Michigan Upon Hire required
• CRT-Case Manager, Certified (CCM) - CCMC Commission for Case Manager Certification preferred

Primary Location

SITE - Priority Health - 1231 E Beltline - Grand Rapids

Department Name

PH - Medical Management

Employment Type

Full time

Shift

Day (United States of America)

Weekly Scheduled Hours

40

Hours of Work

8 a.m. to 5 p.m.

Days Worked

Monday to Friday

Weekend Frequency

N/A

Spectrum Health requires all team members to receive the COVID-19 vaccinations subject to certain exclusions based on the team member’s job category. Spectrum Health is committed to granting reasonable accommodations in accordance with applicable laws.

Accommodation Notice: If you are a qualified individual with a disability, you may request a reasonable accommodation in Spectrum Health's application process. Contact us at 616-486-SHHR (7447).

Spectrum Health grants equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status, height, weight, sexual orientation, veteran status, or any other legally protected

category. See more here.