Health Services Director, RN Health Plan OPS

apartment McLaren Health Care location_onFlint, MI, US

McLaren Health Plan (MHP) is a company with a culture of high performance and a mission to help people live healthier and more satisfying lives. We are looking for a Director, Medical Management to join in leading the organization forward.

MHP is a Managed Care Organization dedicated to meeting the health care needs of each member. MHP offers multiple product lines, including individual and family plans, and Medicaid and Medicare plans to Michigan residents for every stage of life. McLaren Health Plan is accredited by the National Committee for Quality Assurance (NCQA).

MHP values the talents and abilities of all our employees and seeks to foster an open, cooperative and dynamic environment in which employees and the health plan can thrive. As an employee of MHP, you will be a part of a dynamic organization that considers all our employees as leaders in driving the organization forward and delivering quality service to all our members.

Learn more about McLaren Health Plan at https://www.mclarenhealthplan.org

Position Summary:

Provides overall management and direction for the assigned Plan's health services and medical management activities to meet organizational goals. Assumes responsibility for the clinical administrative aspects of utilization review and case management. Integrates medical management processes with all departments within the Plan with a focus on ongoing communication. Directs Medical Management processes to be appropriate; compliant with NCQA standards and regulatory agencies and within budget. Develops and implements departmental policies and procedures as well as documentation of the case management and utilization management processes. Responsible to collaborate in the delivery of the Quality Improvement Performance Plan (QPIP) to facilitate that quality standards are met, with a focus on all assigned NCQA standards. Responsible for the selection, training of health care staff, development and implementation of policies and procedures for inpatient, outpatient and ambulatory utilization that result in delivery of medical care in a cost efficient and quality manner. Assists where necessary or through project management those business ventures undertaken by the Company to ensure its profitable future.

This is a hybrid position with requirements to come onsite as scheduled, Flint, MI.

Qualifications:

Required:

Bachelor's Degree in Nursing, health care or business-related field
Valid RN License in state doing business in
Ten (10) years' experience in a progressively more responsible leadership role in managed care leading utilization, case and/or quality management with demonstrated experience involving clinical and quality analysis and direct interaction with health care providers with at least fou r(4) years' experience in a management role with direct reports, leading or assisting in all phases of effective supervisions (i.e.. recruitment, performance management, training)
Three (3) years' clinical experience in a licensed field
May require weekend supervision for staff

Preferred:

Professional certification in related areas (i.e. Case Management, HEDIS)
Fifteen (15) years' experience and knowledge of Managed Care functions (e.g. medical delivery, regulatory compliance, HEDIS, NCQA)
Affiliation with a Professional Organization

Additional Information

Schedule: Full-time
Requisition ID: 25007356
Daily Work Times: 8:00 am - 5:00 pm
Hours Per Pay Period: 80
On Call: No
Weekends: No

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