POSITION SUMMARY\:To be fully engaged in providing Quality/No Harm, Customer Experience, and Stewardship by\:developing, implementing and monitoring the Case Management structure and systems at Health First Health Plans. To promote operational effectiveness while ensuring the provision of appropriate reimbursable care. Responsible for Case Management (including both Complex and Acute/Catastrophic) and Disease Management at the Health Plans. Oversees the implementation and standardization of best practices throughout the Case Management department at the Health Plans and team building that maximizes efficiencies and talents. The Director Case Management at the Health Plans shall possess comprehensive knowledge of the healthcare industry, familiarity with regulatory and accreditation agencies, strategic planning skills and an understanding of the operations of hospitals and healthcare organizations.Qualification:
QUALIFICATIONS REQUIRED\: Current Florida RN license or MSW required. Bachelor’s Degree from an accredited College or University required, Master’s degree in appropriate healthcare area preferred Certification in Case Management (CCM) preferred. Maintains professional competency by attending managed care seminars, conferences, etc. Minimum of five years of combination of hospital based clinical nursing experience/Utilization management/Quality Management/Managed care experience with minimum of 3 years’ progressive administrative experience. Knowledge of CPT Codes, HIPAA, ICD-9/ICD-10 Codes, Medicare/Medicaid Guidelines, Joint Commission and other regulatory/accreditation agencies. Knowledge of Coordination of Benefits where applicable. (i.e., Worker’s Compensation, Auto Insurance, Short and Long Term Disability). Knowledge of Billing and Claims Processing. Knowledge of alternative treatment options, alternative funding programs and community services and resources. Demonstrated skills in leading and facilitating work efforts. Strong analytical, communication and problem-solving skills. Ability to conduct meetings and speak in front of large groups. A person of good moral character.