Director, Medicare Care Management

This position is a hybrid remote from home and travel position. Travel across the state to clinics and to the main office may be required. Candidates from all areas of Washington state are welcome to apply.

Who we are

Community Health Plan of Washington is an equal opportunity employer committed to a diverse and inclusive workforce. All qualified applicants will receive consideration for employment without regard to any actual or perceived protected characteristic or other unlawful consideration.

Our commitment is to:

• Strive to apply an equity lens to all our work.
• Become an anti-racist organization.
• Create an equitable work environment.

About the Role

Responsible for the direction and coordination of care management activities to manage the care of the member over the continuum of care, including both physical and behavioral health services, for Medicare Advantage and Dual Special Needs Plan members. This role encompasses the effective and efficient management of human, fiscal and other resources, development of staff competency through assessment and education, compliance with regulatory and professional standards and strategic planning, improvement of quality, service levels, safety, customer satisfaction and of collaborative relationships within CHPW and CHNW.

To be successful in this role, you:

• Bachelor’s degree in Nursing or a master’s degree in social work and/or a relevant health field required
• Master’s degree in Nursing, Healthcare Administration, Public Health, or Business strongly preferred
• Current, unrestricted license in the State of Washington as an RN required, if applicable
• Current, unrestricted license in the State of Washington as a Social Worker (LSWAA, LSWAIC) required, if applicable
• Certification as a Case Manager required
• As this position involves traveling on behalf of the Company, a current driver’s license and an acceptable driving record is required
• A minimum of seven (7) years progressively responsible management experience in the areas of case management, population health and/or disease management required, including a minimum of five (5) years progressive experience working with medical and behavioral case management required

Essential Functions and Roles and Responsibilities

• Designs and implements systematic and comprehensive care management policies and procedures that ensure high quality care management application to positively impact member outcomes.
• Administers and ensures care management programs meet compliance and regulatory standards as required by Centers for Medicare & Medicaid Services (CMS), DSNP Model of Care (MOC), Washington Health Care Authority (HCA), and/or National Committee on Quality Assurance (NCQA) for continued accreditation of the health plan, as well as state and federal regulations, quality metrics and evolving models of care.
• Provides oversight of programs within assigned lines of business including development, implementation of program components, quality data collection and monitoring, auditing of program requirements and reporting outcomes to appropriate leadership and committees.
• Responsible for a strong understanding of health plan benefits for all lines of business.
• Defines strategy to identify and assess outlying and high-risk cases to determine plan of care.
• Develops and designs procedures, processes, productivity targets, quality of care and financial goals, and new delivery models for medical and behavioral health care management.
• Collaborates with Medical Directors, Healthcare Analytics, Network Management and other departments as needed to collect, analyze, and report on effectiveness of programs and address quality of care issues. Uses data to guide the development and implementation of health care interventions that improve value to the member.
• Collaborates with internal leaders to deploy a coordinated regional approach to member and provider services in each region across the state.
• Drives strategy for the development, reporting, monitoring, and analysis of department measures that are linked to organizational goals especially as pertains to achieving enrollment targets in care management programs and return on investment projections on care management programs.
• Works collaboratively with other members of the Clinical Services Leadership Team to establish mechanisms and processes to regularly analyze the different Plan populations for variances in clinical and service quality to identify and recommend the highest impact opportunities and department-level strategies for interventions.
• Delegates responsibilities to managers and provides professional development opportunities for team leaders.
• Provides leadership in developing, implementing, and communicating short and long-range plans, goals, and objectives for clinical teams. Aligns team goals with the organization’s vision and strategy.
• Evaluates and integrates Community Health Center processes and programs to ensure that resources are being maximized to improve member care and reduce duplication of work within CHPW.
• Responsible for ensuring the day-to-day supervision of divisional staff including identifying staffing and resource needs, effective hiring, appropriate performance management, staff development, with the goal of developing a cohesive, empowered, and productive work environment.
• Responsible for annual budget preparation and monitoring expenses within the department.
• Participates and/or Chairs/Co-Chairs on committees as assigned. Employees are expected to report to work as scheduled, participate in all assigned meetings, and meet established performance and accountability standards.
• Other duties as assigned; essential functions listed are not necessarily exhaustive and may be revised by the employer, at its sole discretion.

Knowledge, Skills, and Abilities:

• Experience with designing and deploying new programs and teams.
• Demonstrated ability to effectively lead and manage large staffs, including the ability to achieve results through others.
• Experience with identifying, testing and implementing innovative concepts that support special population needs.
• Knowledge of the various components of managed care (quality improvement, disease management, population management, utilization management, and case management) and how they link.
• Actively uses and supports quality improvement principles and methods in an effort to improve inter- and intra-departmental processes.
• Strong project management skills, including the ability to implement new programs and products.
• Excellent ‘customer service’ attitude in relationships with enrollees/patients, staff and external partners.
• Highly effective communicator orally and in writing, with the ability to translate strategy into action.
• Fosters an effective work environment and ensures employees receive recognition, feedback and development.
• Ability to relate and interact with staff at all levels of the organization; exercises sound judgment, builds strong working relationships and demonstrates diplomacy, professionalism, and appropriate confidentiality in dealing with others.
• Strong analytical and problem-solving skills.
• Articulates organizational vision and implements strategic initiatives, with the ability to identify systemic issues to promote real change.
• Working knowledge of M/S office (Word, Excel, Access)
• Knowledge of regulatory and certification requirements and their impact on the organization (for example, HEDIS, CAHPS, and NCQA).
• Perform all functions of the job with accuracy, attention to detail and within established timeframes.

Note: If you think you do not qualify, please reconsider. Studies have shown that women and people of color are less likely to apply to jobs unless they feel they meet every qualification. However, everyone brings different strengths to the table for a job, and people can be successful in a role in a variety of ways. If you are excited about this job but your experience doesn’t perfectly check every box in the job description, we encourage you to apply anyway.

As part of our hiring process, the following criteria must be met:

• Complete and successfully pass a criminal background check.

Criminal History: includes review of criminal convictions and probation. CHPW does not automatically or categorically exclude persons with a criminal background from employment. The applicant’s criminal history will be reviewed on a case-by-case basis considering the risk to the business, members, and employees.

• Has not been sanctioned or excluded from participation in federal or state healthcare programs by a federal or state law enforcement, regulatory, or licensing agency.
• Vaccination requirement (CHPW offers a process for medical or religious exemptions)
• Candidates whose disabilities make them unable to meet these requirements are considered fully qualified if they can perform the essential functions of the job with reasonable accommodation.

Compensation and Benefits:

The position is FLSA Exempt and is not eligible for overtime and has a 15% annual incentive target based on company, department, and individual performance goals. The base pay actually offered will take into account internal equity and also may vary depending on the candidate’s job-related knowledge, skills, and experience among other factors.

CHPW offers the following benefits for Full and Part-time employees and their dependents:

• Medical, Prescription, Dental, and Vision
• Telehealth app
• Flexible Spending Accounts, Health Savings Accounts
• Basic Life AD&D, Short and Long-Term Disability
• Voluntary Life, Critical Care, and Long-Term Care Insurance
• 401(k) Retirement and generous employer match
• Employee Assistance Program and Mental Fitness app
• Financial Coaching, Identity Theft Protection
• Time off including PTO accrual starting at 17 days per year.
• 10 standard holidays, 2 floating holidays
• Compassion time off, jury duty

Sensory/Physical/Mental Requirements:

Sensory* :

• Speaking, hearing, near vision, far vision, depth perception, peripheral vision, touch, smell, and balance.
• Physical* : Extended periods of sitting, computer use, talking and possibly standing
• Frequent torso/back static position; occasional stooping, bending, and twisting.
• Some kneeling, pushing, pulling, lifting, and carrying (not over 25 pounds), twisting, and reaching.

Mental :

• Must have the ability to learn and prioritize multiple tasks within the scope and guidelines of the position and its applicable licensure requirements, many requiring extremely complex cognitive capabilities. Must be able to manage conflict, communicate effectively and meet time-sensitive deadlines.

Travel Required

Yes. Up to 25% local travel to meet with clinics and community partners.

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities