RN Manager Of Care Management For WellMed In San Antonio, TX

UnitedHealth Group Incorporated

• Directs, plans, and supervises activities and priorities within all areas of the department reporting directly to the Director of Care Management.
• Oversees care management functions and ensure compliance with application of criteria from approved standardized guidelines, government mandated regulations and contractual agreements, to include NCAQ, URAC, and CMS.
• Collaborates with the Well Med clinic administrator and/ or Tier I office administration in assuring processes are in place to accomplish all defined goals of the quality metrics.
• Coordinates personnel to meet medical management operational program needs in the market as it relates to care management activities. 
• Fosters open communication with Regional Director by acting as care management liaison and clinical resource in the implementation of strategic changes to corporate policies and projects to ensure smooth transition of operations.
• Communicate both vertically and horizontally regarding UM issues and changes, timely and appropriately. Participates in market meetings and addresses UM issues and changes
• Reports to senior leadership on the status of organizational goals within the specified market.
• Provides monthly operational reports of case management activities to senior management.
• Monitors care manager’s prospective, concurrent and retrospective assessment, planning, implementation, tracking, monitoring, coordination, reconciliation and evaluation of the managed care members across the continuum of care to include the complete transition of care to outpatient care.
• Ensures all medical management operations and administrative processes are in place to meet the needs of clinic staff, customers, and patients.
• Tracks and trends outcomes for potential improvements in the care management process.  Creates monitors, evaluates and disseminates program and productivity reports weekly, monthly, and as needed.
• Interviews, hires, and retains quality nursing staff to meet the needs of the department.
• Evaluates nurse performance and recommend merit increases, promotions, and disciplinary actions.
• Attends, and assists with the facilitation of the weekly PCC meetings at each clinic within assigned territory and participates in committees as requested and monitors team participation and performance during meetings.
• Monitors and oversees the reporting of all quality issues to UM Medical Director and potentially the Health Plan for accuracy and frequency and ensure staff participation in reporting of quality issues.
• Assist with physician members in their awareness of preferred contracted providers and facilities.
• Mentors and serves as an operational resource for care management staff, PHC market providers, internal departments, and external partners regarding customer service issues. 
• Actively participates in process improvement planning and implementation.
• Exercises cost containment of supplies, travel and overtime etc.
• Performs all other related duties as assigned.

• Bachelor of Science in Nursing (BSN) required (Eight additional years of experience beyond the required years of experience may be substituted in lieu of a bachelor’s degree).
• Active Registered Nurse (RN) license in the applicable state required.
• CCM certification or proof that certification has been obtained within one year of hire date.
• Five or more years of healthcare experience to include experience in a managed care setting, hospital setting and/or physician practice setting required.
• Five or more years experience in managed care and/or disease/utilization management with a minimum of three years at a management level. 
• Ability to establish and maintain effective working relationships with employees, managers, healthcare professionals, physicians and other members of senior administration and the general public.
• Data mining, analytical and reporting skills required.  Must be able to review and interpret data to make recommendations to senior-management.
• In and /or out-of-town travel required as deemed necessary by business need.

• Master’s Science in Nursing.
• Prior multi-site regional operations management responsibility preferred.