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RN Director PHM Care Management Texas

company vehicle
United States, Texas, San Antonio
March 01, 2024

Opportunities at WellMed, part of the Optum family of businesses. We believe all patients are entitled to the highest level of medical care. Here, you will join a team who shares your passion for helping people achieve better health. With opportunities for physicians, clinical staff and non-patient-facing roles, you can make a difference with us as you discover the meaning behind 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.

If you are located within the TX area and have a compact licenses, you will have the flexibility to work remotely* as you take on some tough challenges.

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

  • Responsible for 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 consistently executes disciplinary actions/PIPs
  • 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

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 current license in Texas, or other participating states
  • Case Management Certification (CCM) or ability to obtain within 18 months of hire
  • 8+ years of experience in managed care and/or disease/utilization management with 3+ years at the management level or above
  • 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
  • Proven ability to effectively plan programs and evaluate accomplishments
  • Proven ability to present facts/recommendations in oral and written form
  • Proven ability to analyze facts and exercise sound judgment arriving at proper conclusions
  • Proven ability to plan, supervise and review the work of professional and support staff
  • Proven ability to apply policies and principles to solve everyday problems and deal with a variety of situations
  • Proven ability to exercise initiative, problem-solving, decision-making
  • Proven ability to establish and maintain effective working relationships with employees, managers, healthcare professionals, physicians and other members of senior administration and the general public.
  • Proven effective written and verbal communication skills
  • Willing or ability to in and/or out-of-town travel

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

Physical & Mental Requirements:

  • Ability to stand for extended periods of time
  • Ability to properly drive and operate a company vehicle

*All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.

Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer 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.

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