The Director of Care Management is responsible for planning, organizing, and directing Hoag Clinic operations of all areas related to Utilization Management, Care Management (Ambulatory, Facility Discharge Coordination, High Risk and Complex), Disease Management, Regulatory Compliance, and Quality Improvement for members and beneficiaries in value based payment models. The role will also help with the development of a multi-disciplinary Virtual Care team that integrates Clinical Care teams with Member Services. The Director coordinates duties with appropriate personnel to meet operational program needs that ensure compliance with state, federal, and health plan requirements; Medicare guidelines; and NCQA standards. Director is responsible for implementing operational policies and procedures; integrating and updating current clinical practice guidelines. They will be responsible for oversight and/or performance of employee counseling, appraisals, training and development. The success of this position requires the ability to foster communication and teamwork between physicians, clinic staff, medical management staff, corporate departments, vendors, and senior leadership. The Director will assist senior leadership with longterm planning priorities to maintain operations assuring activities are appropriately integrated into Organizations strategic direction.

Essential Functions:
• Directs, evaluates and implements medical management programs in accordance with the mission,
philosophy, and strategic objectives for the organization.
• Develops implements and monitors programs that optimize patient/family and/or member satisfaction
with cost-effective, efficient care management programs by advocating for patients and resolving patient
care issues.
• Maintains a high level of multi-product knowledge including; PPO, HMO, IFP, Mid/Large, ASO,
Medicare, SNP, Medi-Cal, Shared Advantage (TPA Integration).
• Sets the strategic direction of projects. Determines goals and priorities with senior management team.
Leads, contributes, and provides clinical and technical leadership to highly visible, large, complex multidimensional analytical clinical projects that identify and resolve medical management issues of strategic
importance to the organization.
• Develops workflows, policies and procedures to obtain and maintain Medical Management “Delegated”
status and operationalize requirements set by delegation Agreements; Health plan contracts; Provider
contracts, Divisions of Financial Responsibility (DOFR) Divisions of Special Needs Plans
Responsibilities (DOSR) Evidence Of Coverage (EOC); Health Plan Operations Manuals; Contracted
Provider Lists (CPLs) for Hoag Clinic/MSO.
• Defines and implements organizational structure to facilitate effective delivery of medical management
functions.
• Establishes team membership and negotiates time commitments and resources. Develops proposals
outlining project structure, approach, and work plan. Provides staff leadership to project teams, as well as
manages work of outside consultants when needed.
• Collaborates with Medical Management Leadership team, including Medical Director, Chief Medical
Officer, to generate and implement annual UM, QI and SNP work plans and programs as well as educate
and communicate expectations with providers.
• Analyzes and reports utilization, quality and performance metrics in collaboration with physician and
clinical leaders, directors, MDs, all levels of managers and other service area personnel to identify
Job Summary
Job Specific Essential Functions
medical management improvement strategies, opportunities, develop, and implement action plans with
stated outcomes and timeframe.
• Ensures the timely preparation of reports and budgets for dissemination to stakeholders including but not
limited to utilization reports, financial data, corrective action plans (CAPS), quarterly reports and annual
audits in accordance with contracted plans, Industry Collaborative Efforts (ICE), Centers for Medicare
and Medicaid (CMS), Health Plan, National Committee on Quality Assurance (NCQA), and Department
of Managed Healthcare (DMHC).
• Develops, analyzes and designs data gathering and reporting mechanisms that:
o identify and report trends
o identify potential areas for improvement in cost structures
o resolve operational issues
o satisfy business requirements
o promote efficiency
o improve resource consumption
o maximize productivity and performance
o measure and improve utilization and promote quality patient care
o meet performance-based department metrics
• Works collaboratively with all departments by analyzing utilization reports or financial data and makes
appropriate recommendations for improvements.
• Evaluates current areas of responsibility to determine opportunities for program improvements.
Implements any needed modifications and improvements to existing programs.
• Determines the appropriate staffing requirements and develops processes to interview, hire, train and
maintain department staff including management of payroll functions for department staff.
• Provides oversight and leadership to staff responsible for creating and driving the implementation of
operating plans, which are required to support immediate and long-term business strategies.
• Develop communication plans with stakeholders as required to facilitate goals and objectives that will
achieve and maintain organizations delegation status.
• Conducts and attends educational offerings to keep abreast of change and complies with licensing
requirements. Assists in the growth and development of associates by sharing knowledge with others
through departmental meetings, trainings, patient care committees, and interdisciplinary team meetings as
required for care coordination activities.
• Perform any additional/miscellaneous duties (not inclusive of job description) as requested by the
management team within the scope of knowledge/ability.

Education, Training and Experience

Required:

• Bachelor of Science degree, in Nursing, Management, Business Administration or related field.

• Five to seven years’ experience in managed care and/or disease/medical management with a minimum of five years at the management level in managed care organization.

• Five years work experience applying evidence-based criteria (i.e.: Milliman, Interqual); Health plan medical policy / clinical coverage guidelines.

• Five years work experience implementing requirements set forth by regulatory agencies. This includes but is not limited to: contracted Health Plans, Centers for Medicare and Medicaid (CMS), NCQA (National Committee for Quality Assurance) SNP (Special Needs Plans); DMHC (Department of Managed Health Care); and ICE (Industry Collaborative Effort).

Preferred:

• Master degree of Science degree, in Nursing, Management, Business Administration or related field.

• Familiarity with Epic Healthy Planet module

• Master’s degree in Business/Healthcare Administration

• Experience working in an integrated healthcare delivery system

Skills or Other Qualifications

Required:

• Mid-level executive, able to develop collaborative working partnerships with business units and other functional leaders to successfully achieve their goals through excellent interpersonal communication (one-on-one and group) and demonstrate solid customer service skills by working both independently and as part of a team. This includes the ability to effectively communicate with all stakeholders to professionally and diplomatically debate difficult topics while supporting the Organization’s Vision and Mission.

• Strong analytical skills, with a proven ability to develop and document resolution of complex issues through data driven decisions.

• Prior experience in developing business strategies, designing organizational structure and workflows, defining, establishing and managing healthcare business.

• Experience in evaluating, negotiating, and managing financial and operational arrangements with third party vendors and/or providers.

• Experience scaling a team and leading teams through change

License and Certifications

Required: Current California Registered Nurse (RN).

Preferred: N/A