Director, Medical Case Management (Western Zone)

Director Of Managed Care And Clinical

AmTrust Financial Services, a fast growing commercial insurance company, has a need for a Director of Managed Care and Clinical, for our Western Zone.

PRIMARY PURPOSE: Reporting to the Head of Managed Care and Clinical, the Director of Managed Care will have responsibility for managing the performance, productivity, and medical management outcomes of AmTrust's managed care operations. This role will have oversight of telephonic nurse case management, pharmacy management nurses and Utilization review nurses to deliver optimal claim results.

Responsibilities

• Provide leadership and guidance for field managed care operations in assigned zone.
• Execute medical management strategy; analyze medical management results and create annual operational goals and objectives for claim handling operation.
• Plan, organize, and monitor the daily activities of managed care operations in assigned zone.
• Ensure all Managed Care processes and protocols are effectively executed.
• Serve as a technical and business resource for nurse case management
• Monitor and analyze significant legal developments and legislative changes that may affect medical management. Collaborate with Director of Medical Strategy and Clinical Optimization to address changes.
• Participate in the effective selection, coaching, medical education and clinical development of nurse case managers.
• Manages project development/enhancements through coordination with WC operations
• Employ performance management and performance review processes to maximize performance of employees, correct performance problems, provide development opportunities and promote effective communication with employees.
• Ensure claim quality in accordance with best practices and company guidelines.
• Maintain appropriate staffing levels in conjunction with workloads.
• Select, train and manage staff. Plan staff responsibilities and manage activities, utilizing staff resources effectively.
• Ensure appropriate execution of quality assurance processes, inclusive of identification of strengths, deficiencies and implementation of action plans focused on improved results.
• Lead by example in effectively supervising, coaching, developing, motivating, and evaluating staff.
• Analyze and report on field claim activities and initiatives.
• Ensure regulatory compliance with jurisdictional workers' compensation rules and statutes.

Qualifications

• Active unrestricted RN license in a state or territory of the United States with eligibility to get and/or renew a multistate license required. Bachelor's degree in nursing (BSN) from accredited college or university or equivalent work experience preferred. Certification in case management, pharmacy, rehabilitation nursing or a related specialty is highly preferred.
• Seven (7) years of related experience or equivalent combination of education and experience required to include two (2) years of direct clinical care OR two (2) years of case management/utilization management required.
• Five + years of direct nurse management experience.

Skills & Knowledge

• Knowledge of pharmaceuticals used to treat pain
• Knowledge of behavioral health
• Knowledge of pain management process
• Knowledge of drug rehabilitation process
• Knowledge of workers' compensation laws and regulations
• Excellent oral and written communication,
• Ability to prepare presentation documents and present to senior leadership
• Advanced computer skills to include Microsoft Products
• Proven ability to manage organizational change, to involve and influence others to accept new ideas or innovative approaches, to lead in a team based organization
• Ability to manage a diverse team including clinical professionals in multiple locations
• Ability to develop reports, metrics and improvement plans
• Ability to interact collaboratively and work effectively with a multi-functional team and throughout the organization; fosters an environment of shared responsibility and accountability
• Experience applying medical management treatment guidelines
• Experience with writing and implementing program level policy and procedures
• Analytic and interpretive skills
• Strong organizational skills
• Excellent interpersonal skills
• Excellent negotiation skills
• Ability to work in a team environment
• Ability to meet or exceed Performance Competencies
• Experience with State and external accreditation managed care audits and reviews
• Prior experience developing and leading nurse case management, medical director and clinical teams
• Demonstrated results in developing strategic plans and executing key initiatives
• Ability to collaborate across functional lines and leaders
• Strong communication and analytical skills