Director Care Management WellMed Healthcare Texas

WellMed, part of the Optum family of businesses, is seeking a Registered Nurse to join our team in Texas. Optum is a clinician-led care organization that is changing the way clinicians work and live.

As a member of the Optum Care Delivery team, you’ll be an integral part of our vision to make healthcare better for everyone.

At Optum, you’ll have the clinical resources, data and support of a global organization behind you so you can help your patients live healthier lives. Here, you’ll work alongside talented peers in a collaborative environment that is guided by diversity and inclusion while driving towards the Quadruple Aim. We believe you deserve an exceptional career, and will empower you to live your best life at work and at home. Experience the fulfillment of advancing the health of your community with the excitement of contributing new practice ideas and initiatives that could help improve care for millions of patients across the country. Because together, we have the power to make health care better for everyone. Join us and discover how rewarding medicine can be while Caring. Connecting. Growing together.

The Director of Care Management is responsible for planning, organizing, and directing the assigned regional operations for Care Management services. The Director coordinates duties with appropriate personnel to meet operational program needs, ensures compliance with state and federal health plan requirements, Medicare guidelines and URAC/NCQA standards; develops and implements policy and procedures; updates and integrates current clinical practice guidelines; performs employee counseling, performance appraisals, and oversights employee training and development. The success of this position requires the ability to foster communication and teamwork between physicians, market care management team, utilization management staff, corporate departments, vendors, and senior leadership. This position is responsible for oversight and evaluation of all Care Management programs. The Director will assist senior leadership with long-term planning initiatives to maintain operations assuring activities are appropriately integrated into strategic direction, as well as the mission and values of the company. 

Primary Responsibilities:

• Participates, provides input, and impacts outcomes of the following:
  • Medical Management Committee 
  • Market Success Meetings/ Best Year Yet 
  • Care Coordination Steering Committee
  • Market Patient Care Coordination Meetings
  • Tier I Provider Market Meetings
• Planning and implementing assigned market and regional market success initiatives with each market care management and operations team to include 
  • Overall Health Care Cost PMPM 
  • Quality of Care Metrics 
  • Acute patient care episodes through Admits/k, Readmits %, ER visits/k
• Directs, plans, and supervises activities for assigned team/region 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 in each assigned market mentoring team members, fostering relationship with market operations team, and providing resources for vendor and provider education needs
• Provides effective problem solving, works as a care management liaison and resource with all customers internal and external to provide optimal customer satisfaction
  • Maintains current knowledge of health plan benefits and provider network including inclusions and exclusions in contract terms
  • Guides physicians in their awareness of preferred contracts and providers and facilities
• Participates in the development, planning, and execution of continual process improvement efforts, policies and procedures, and regulatory compliance functions related to care management activities
  • Coordinates all activities related to delegated and regulatory requirements 
  • Develops initiatives for process improvement of care management programs
  • Develops new policies, procedures, job aids, and work flows that enhance operating efficiency of the care management programs or activities
  • Evaluates the success of process improvement efforts and implements solutions for growth opportunities
  • Evaluates care management staff performance by providing monthly management level and role level report cards 
• Provides coaching for performance success, recommends merit increases, and consistency executes disciplinary actions
• Interviews, hires, and retains quality licensed staff to meet business needs
• Ensures the timely preparation of reports and records for dissemination to stakeholders to include: 
  • Monthly Market Metrics 
  • Market Pilot Outcomes 
  • Market Success Initiative Key Outcomes and Milestones 
  • Monthly Team Member Report Cards 
• Completes and manages regional budget effectively 
• Conducts and/or participates in departmental meetings, patient care coordination meetings, and interdisciplinary team meetings as required for care management activities
• Conducts annual evaluation of regional care management program
• Performs all other related duties as assigned

In 2011, WellMed partnered with Optum to provide care to patients across Texas and Florida. WellMed is a network of doctors, specialists and other medical professionals that specialize in providing care for more than 1 million older adults with over 16,000 doctors’ offices. At WellMed our focus is simple. We’re innovators in preventative health care, striving to change the face of health care for seniors. WellMed has more than 22,000+ primary care physicians, hospitalists, specialists, and advanced practice clinicians who excel in caring for 900,000+ older adults. Together, we’re making health care work better for everyone.

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 of Science degree, in Nursing, Management, Business Administration or related field (or 8+ years of experience in the managed care, disease management, or utilization management field)
• Registered Nurse with unrestricted, current license in Texas or applicable state of employment
• Case Management Certification (CCM) or ability to obtain CCM within 12 months after the first year of employment
• 8+ years of experience in managed care and/or disease / utilization management with 3+ years at the management level or above
• Experience to effectively plan programs and evaluate accomplishments
• Experience presenting facts / recommendations in oral and written form
• Experience analyzing facts and exercising sound judgment arriving at proper conclusions
• Experience planning, supervising and reviewing the work of professional and support staff
• Experience applying policies and principles to solve everyday problems and dealing with a variety of situations
• Experience exercising initiative, problem-solving, decision-making
• Experience establishing and maintaining effective working relationships with employees, managers, healthcare professionals, physicians and other members of senior administration and the general public
• Knowledge of federal and state laws and URAC/NCQA regulations relating to managed care, disease management, utilization management, transition planning and complex care case management
• Knowledge of basic principles and practices of clinical nursing
• Knowledge of referral processes, claims, case management, and contracting and physician practices
• Knowledge of fiscal management and human resource management techniques
• Proficient with computer software programs, to include: word processing, spreadsheets graphics and databases
• Ability to travel in or out of town when needed

Preferred Qualifications:

• Master’s degree
• 10+ years of experience in managed care and/or disease management with 5+ years at a management level
• 3+ years of experience working in a call center environment
• Multi-site regional operations management responsibility
• Proven effective written and verbal communication skills

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.