Director Medical Management - HP Utilization Management

Summary

Responsible for the development, implementation, oversight, monitoring, and continuous improvement of Care Management programs designed to ensure members and beneficiaries receive the right care, by the right provider, in the right setting, and at the right time. Leads efforts to improve healthcare quality, member engagement, clinical outcomes, health equity, and healthcare affordability through data-driven population health strategies and evidence-based care management interventions. Oversees organizational readiness and ongoing compliance with NCQA accreditation standards, HEDIS performance requirements, regulatory obligations, and contractual requirements.

Responsibilities

• Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders.
• Provide leadership, direction, and strategic oversight for Care Management, Population Health, and care coordination programs.
• Utilize population-based analytics, predictive modeling, and risk stratification methodologies to identify opportunities for intervention and resource optimization.
• Align care coordination initiatives with HEDIS improvement plans, NCQA standards, quality improvement initiatives, and value-based care strategies.
• Establish annual goals focused on improving care coordination effectiveness, reducing avoidable utilization, increasing care gap closure, enhancing quality measures, and improving member outcomes.
• Monitor emerging industry trends, regulatory requirements, and best practices to advance organizational capabilities in Care Management and Population Health.
• Guide managers, supervisors, care coordinators, social workers, nurses, and other healthcare professionals in achieving organizational objectives and performance expectations.
• Ensure Care Management staffing models, workflows, interventions, and clinical practices support member needs, contractual requirements, and accreditation standards.
• Establish accountability for performance measures including engagement rates, care plan completion, transition-of-care effectiveness, care gap closure outcomes, member experience, and clinical outcomes.
• Lead the development and implementation of standardized care coordination workflows supporting care transitions, post-discharge follow-up, emergency department diversion, chronic disease management, and complex case management.
• Establish processes to identify members at elevated clinical, utilization, or social risk and ensure timely intervention through risk-stratified care management programs; drive initiatives that address social determinants of health (SDOH), health-related social needs, and barriers to care that may impact quality outcomes and care gap closure.
• Leverage population health analytics, predictive modeling, and care management technology platforms to proactively identify intervention opportunities and optimize resource allocation.
• Utilize outcomes data and audit findings to continuously improve program design and effectiveness.
• Present performance results, outcome measures, audit findings, and recommendations to executive leadership and governing committees.
• Lead organizational readiness activities associated with NCQA accreditation, re-accreditation, and ongoing compliance monitoring.
• Conduct routine audits, evaluations, and readiness assessments to ensure regulatory compliance and accreditation preparedness.
• Maintain documentation, policies, procedures, and evidence required for accreditation activities.
• Work collaboratively with providers, hospitals, health systems, community organizations, military treatment facilities, and external partners to support coordinated, high-quality care delivery.
• Develop and implement member engagement strategies that promote participation in Care Management programs, preventive health activities, and chronic disease management initiatives.
• Support member activation, self-management, health literacy, and shared decision-making initiatives.

Job Requirements

Education/Skills

• Bachelor's Degree in Nursing, Social Work, Healthcare Administration, Public Health, or related field required.
• Master's Degree in Nursing, Public Health, Healthcare Administration, Business Administration, or related field preferred.
• Strong working knowledge of Population Health Management, Care Management operations, care coordination, HEDIS measures, quality improvement methodologies, NCQA standards, healthcare analytics, and value-based care principles.
• Demonstrated ability to lead large-scale clinical programs and cross-functional improvement initiatives.

Experience

• 3+ years of full-time acute care nursing, social work, case management, population health, health plan operations, or related clinical experience required.
• 3+ years of progressive leadership experience in Care Management, Population Health Management, Health Plan Operations, Quality Management, or related healthcare settings required.
• Experience leading care coordination, care gap closure, quality performance improvement, HEDIS initiatives, population health programs, and multidisciplinary clinical teams required.
• Experience supporting NCQA accreditation, regulatory audits, quality improvement activities, and health plan compliance functions preferred.
• Experience utilizing Epic, Healthy Planet, Compass Rose, population health analytics platforms, or similar healthcare technology solutions preferred.

Licenses, Registrations, or Certifications

• RN or BSW license in the state of employment required.
• CCM (Certified Case Manager), ACM (Accredited Case Manager), CPHQ (Certified Professional in Healthcare Quality), or other relevant certification preferred.
• NCQA, Population Health, Quality Improvement, Care Management, or Healthcare Leadership certifications preferred.

Work Schedule

8AM - 5PM Monday-Friday

Work Type

Full Time