Medical Management Director - CSMV(Managed Care & TRICARE Experience Preferred)

📋 Description

• • Lead the strategic direction and day-to-day operations of CareSource Military & Veterans' (CSMV) integrated medical management model, encompassing Utilization Management (UM), Case Management (CM), Behavioral Health (BH), Population Health (PH), Clinical Quality Management (CQM), and Pharmacy Management.
• • Ensure the seamless and compliant execution of all medical management functions, adhering strictly to TRICARE requirements and reporting obligations to maintain operational excellence and regulatory adherence.
• • Drive the delivery of high-quality, cost-effective healthcare services by implementing best practices and innovative strategies across all managed care domains.
• • Actively work to reduce unwarranted variation in care delivery and minimize waste within the healthcare system, contributing to improved patient outcomes and resource optimization.
• • Play a pivotal role in the reduction of Total Cost of Care (TCOC) for the TRICARE Prime Competitive Plans Demonstration, demonstrating a commitment to financial stewardship and efficient healthcare provision.
• • Provide robust strategic and operational leadership, guiding the Medical Management function to achieve its objectives and align with the broader goals of CSMV.
• • Oversee and direct all utilization management activities, including prospective, concurrent, and retrospective reviews of beneficiary care to ensure appropriateness, medical necessity, and adherence to established clinical guidelines.
• • Manage and refine prior authorization processes, ensuring timely and accurate determinations for services and benefits, thereby facilitating access to necessary care.
• • Supervise concurrent review and census management for inpatient stays, proactively identifying potential issues and facilitating efficient transitions of care.
• • Lead the clinical appeals processes, ensuring fair and thorough evaluations of medical necessity and factual appeals, and coordinating effectively with qualified clinical reviewers to uphold patient rights and clinical standards.
• • Ensure the delivery of effective and compassionate case management services, supporting members through transitions in and out of the plan, managing chronic conditions, and facilitating seamless post-discharge transitions of care to prevent readmissions and improve recovery.
• • Develop and implement innovative population health strategies, including targeted outreach programs designed to engage and support high-risk populations and individuals managing chronic conditions, promoting proactive health management.
• • Oversee the integration and coordination of behavioral health services with medical and case management operations, fostering a holistic approach to member care and well-being.
• • Ensure rigorous compliance, performance monitoring, and accurate reporting for all clinical quality and pharmacy management programs, maintaining high standards of care and operational integrity.
• • Guarantee the timely and accurate completion of all Government-required medical management deliverables and reports, meeting all contractual obligations and regulatory expectations.
• • Foster a culture of continuous improvement within the Medical Management team, encouraging innovation, professional development, and a commitment to excellence.
• • Collaborate effectively with internal and external stakeholders, including healthcare providers, government agencies, and other CareSource departments, to optimize care delivery and achieve shared goals.
• • Analyze performance data and key metrics to identify trends, opportunities for improvement, and areas of risk, translating insights into actionable strategies.
• • Stay abreast of industry trends, regulatory changes, and best practices in managed care and military health, ensuring that CSMV remains at the forefront of healthcare delivery for veterans and military families.
• • Manage departmental budgets and resources effectively, ensuring fiscal responsibility and optimal allocation of funds to support program objectives.
• • Mentor and develop direct reports, fostering a high-performing team environment and promoting career growth within the organization.
• • Uphold the mission and values of CareSource, demonstrating a commitment to improving the health and well-being of the military and veteran community.
• • Perform any other job-related duties as requested by leadership to support the overall success of the CSMV program.