The Medical Services Program Manager provides leadership to the continuous Quality Improvement Process for all aspects of work related to medical services. Leads and analyzes clinical program measurement data for opportunities for improvement and impactable provider and/or member contracts, trends, for UM/CM by applying sound statistical methodology. Analysis of data must be integrated across medical and pharmacy claims, care management program activity and outcomes and predictive modeling or other vendor data. This position provides guidance to regional directors and medical directors regarding CQI process as related to Utilization Management or Case Management. Develops and maintains UM/CM policies and procedures, using a process that involves medical leadership input. The Program Manager conducts ongoing review of Utilization Management/Case Management literature and current clinical evidence of effectiveness. The Program Manager performs in-depth research of best practice initiatives and benchmark Health Plans, and competitor information. The incumbent develops reports and recommendations for action. The Program Manager serves as a subject matter expert for the development of staff training and employer proposals and education.
• Responsible for the analysis of Utilization Management/Case Management data, program outcomes, measurement results for all Health Plan, Univera and RMSCO regions and lines of business.
• Conducts comparative analysis of benchmark and competitor results and compiles reports to management.
• Identifies statistically significant opportunities for improvement and conducts drill down analysis of the measurement data for those identified opportunities. Conducts research on the evidence based improvement interventions for identified barriers.
• Works closely with the Quality Health Informatics, Employer Group Reporting, Data Warehouse project resources/leads, and Actuarial Dept contacts, for consultative purposes to obtain highly complex data and reports, as necessary.
• Responsible for design and oversight for overall program metric and performance reporting in collaboration with Manager Medical Services Program Development including summary and communication to staff and senior management.
• Conducts research on best practices for benchmark performing Plans. Provides reports and recommendations to the Utilization Management/Case Management team for action.
• Provides guidance to the Utilization Management/Case Management team in conducting research for evidence based clinical improvement initiatives.
• Organizes and facilitates large educational and re-engineering sessions. Facilitates interdepartmental coordination and communication with all Care Management functional areas, such as, but not limited to Case Management, Utilization Management, Behavioral Health, Medical Claim Review and Audit, Health Promotion, Disease Management, to support delivery of high quality, timely customer solutions.
• Collaborates with other clinical departments in regards to cross functional business processes, accreditation requirements, and regulatory issues.
• Leads and facilitates processes needed to analyze and improve processes and workflows. Serves as project manager for initiatives specific to Medical Services. Represents Medical Services on Health Plan-wide cross functional process improvements teams, as requested by manager/director.
• Develops and maintains policies and procedures for the Utilization Management/Case Management process. Ensures compliance with DOH, NCQA, URAC and Medicare requirements.
• Primary responsibility for vendor relationships associated with vendor partners such as predictive modeling partner, imaging service partner. Establishes & maintains relationships, contract terms, and maintains accountability for vendor performance in accordance with terms. Ensures appropriate data integration with Health Plan feeder core IT systems,
• Serves as subject matter expert in maintaining the Utilization Management/Case Management training program for Medical Services and other related clinical staff.
• Facilitates the development and implementation of hospital, practitioner, and office staff improvement initiatives.
• Collaborates in providing input for hospital and physician performance profiling in accordance with the Company’s profiling strategy.
• In collaboration with and at the request of the Director of Clinical Employer Support, meets with employer groups to present Medical Management/Member Program management reports, and provides consultation on activities that will improve program results or help manage costs.
• Accepts responsibility for personal professional education requirements per departmental policy.
• Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values and adhering to the Corporate Code of Conduct.
• Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
• Regular and reliable attendance is expected and required
• Performs other duties as assigned by management.
• Registered Nurse with valid and current NYS nursing license with a minimum of five years’ experience working with utilization management/case management programs or other clinically related program development. Bachelor’s degree in related field.
• Or, Master’s Degree in health related field/or other allied health professional with current NYS license with minimum of five years’ experience working with utilization management/case management programs or other clinically related program development.
• Very strong working knowledge of Corporate Medical Policies, InterQual and Milliman & Robertson guidelines, NCQA standards, URAC requirements, HEDIS, CMS requirements, and NYSDOH medical management mandates & program requirements.
• Demonstrates effective verbal communication skills and superior writing capabilities. Reads, analyzes, and understands complex statistical documents.
• Ensures accuracy of data. Demonstrates expert level ability of using statistical mathematics, research skills and calculations, and the use of software in the Utilization Management/Case Management process.
• Exhibits excellent organizational, planning, and project management skills. Makes decisions using solid judgment skills to impact identified problems.
• Must have the ability to travel.
Must be able to regularly travel within the Health Plan Regions.
Must be able to work beyond normal work hours and respond to changing needs on short notice.
In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.
Equal Opportunity Employer