Clinical Director of Care Management (ACA product)

It’s an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.

Job Summary

Under the direction of the Vice President of Care Management, the Clinical Director of Care Management is responsible and accountable for the overall strategic direction, oversight, analysis, clinical compliance and data reporting for our QHP Members. The Director ensures that the delivery of care management and related care coordination activity is based on specialized clinical expertise, critical thinking, established protocols, policies, procedures, practice standards, and applicable contract and regulatory care requirements. The Director represents the Plan in external meetings with key customers, in particular regulatory and advocate stakeholders.

Our Investment In You

• Full-time remote work
• Competitive salaries
• Excellent benefits
  
  

Key Functions/Responsibilities

• Optimize nursing, social work and behavioral health practices which result in demonstrated high quality, cost effective and member centric care. Implement work process which consistently identify high risk members and rising risk members, effectively manage member crisis and service recovery. Coordinate, collaborate and supervise the collaboration with all community partners and pharmacy to ensure that all services are reliably delivered in the highest quality and member centric manner.
• Demonstrate a passion for leading positive change by continuously improving and defining innovative care management interventions, keeping the team continuously informed about mandates, regulations, and best practice innovations.
• Work with the staff to continuously optimize member education around self-management, disease management, advance healthcare planning and end of life. Ensure that the member and circle of support can actively participate.
• Promote best practice in impacting social determinants of health and homelessness and help to establish a framework for continued objective evaluation of the interventions.
• Promote standardization of workflows, policies and documentation to ensure that there is a solid data base from which to report and evaluate the program.
• Promote continuing education and professional development for each staff member in an individualized manner.
• Provides leadership to ensure best utilization of resources in obtaining organizational goals, regulatory compliance, adhering to corporate policies through oversight of daily operations, assessment of adequacy of staffing, and adherence to standards of care management staff
• Works in close collaboration with and guidance from the Chief Clinical Officer of Quality department.
• Integrates knowledge and experience in health care delivery in managed care and population health into provider network while seeking opportunities to improve contractual relationships and partnerships with organizations/companies/agencies focused on services and programs to increase quality of life and health of all members.
• Monitors staff productivity and balances staffing and responsibilities accordingly
• Oversees the assessment of and care planning for members in the care management program and enhances member centric care planning which is holistic and incorporates the complexities of managing members with multiple co-morbid conditions as well as challenging socioeconomic situations.
• Utilizes metrics and reports to ensure work is allocated timely and appropriately and meets regulatory compliance requirements, member needs, and performance standards
• Collaborates cross-functionally with internal stakeholders, (customer service, marketing, product, finance, utilization management, pharmacy, behavioral health) and external stakeholders to ensure operational requirements are facilitated to support care management
• Consults and collaborates with the Quality Improvement and Clinical Informatics departments on an ongoing basis to ensure the care management program, metrics and performance are consistently meeting targets established for MassHealth Quality Improvement Goals, Annual Quality Improvement Work Plan goals and External Quality Review Organization goals, and other initiatives, as appropriate
• Engages in clinical quality initiatives and manages measures associated with key performance indicators
  
  

Qualifications

Education:

• Graduate of an accredited school of nursing
• Bachelor’s degree in Nursing required. Candidates with an Associate’s Degree in Nursing will be considered if they also have extensive experience working within managed care or Medicare/Medicaid care management programs.
• Master’s degree in nursing or health related/public health field preferred
  
  

Experience

• A minimum of 7 years of progressive care management leadership experience within managed care or a similar health care environment
• A minimum of 7 years of experience successfully managing people and leading teams
• Experience using data and metrics to monitor performance, allocate workloads, and monitor medical and utilization trends
• Experience managing projects, programs, complex change initiatives, and/or regulatory audits and regulatory compliance
• A minimum of 7 years of experience in developing and executing strategic business plans and budgets with a track record of achieving results
• Experience working with QHP, geriatric, Medicaid/Medicare or other health insurance populations
• Experience work with an integrated care model/use of supportive services
• Experience in program development and/or health policy
• Experience in managing remote and field teams.
• Experience in population health management, provider-based and alternative models of care preferred.
  
  

Experience Preferred/Desirable

• Expertise in clinical/care management information systems such as Jiva
• Experience managing teams in health insurance programs
• Experience leading transitions of care programs and familiarity with community resources and advocacy programs
  
  

Certification Or Conditions Of Employment

• Active, unrestricted MA and NH Nurse licenses, required. Licensure from a compact state may cover requirement(s) based on MA and NH current rules
• Certification in case management (CCM) preferred
• Ability to take after hours calls, including evening/nights/weekends
  
  

Competencies, Skills, And Attributes

• Excellent oral and written communication skills; ability to interact within all levels of the organization as well as with external contacts.
• Ability to leverage analytics, metrics, and an ability to produce and interpret data.
• Proven process improvement skill
• Proven ability to partner, collaborate with, and influence relevant stakeholders internally across departments and the BMC Health System as well as externally with providers, government contacts and regulators. Excellent relationship and consensus-building skills.
• Ability to multi-task, prioritize, and deliver in a demanding and constantly changing environment.
• Ability to document and articulate information to senior leaders clearly and concisely.
• Demonstrated ability to successfully plan, organize and manage programs and projects
• Excellent organizational skills
• Strong independent judgment, critical and analytical thinking, and problem-solving skills required
  
  

About WellSense

WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances. WellSense is committed to the diversity and inclusion of staff and their members.

Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status. WellSense participates in the E-Verify program to electronically verify the employment eligibility of newly hired employees

Required Skills

Required Experience