McLaren Health Plan, recognized by Modern Health Care as one of the 100 Best Places to Work in Health Care for four years in a row, is seeking a Manager to join our Medical Management team!
Responsible for all aspects of the Medical Management process from the determination of the appropriateness of care to ultimately improving health outcomes. Responsible for the education, monitoring and evaluation of the Medical Management staff for all product lines. Evaluates, designs, implements and adjust workflows to ensure accuracy and department efficiencies. Manages 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 for the ongoing assessment and delivery of the Quality Improvement Performance Plan (QPIP) to facilitate that quality standards are met, with a focus on all assigned NCQA standards. Intervenes with providers when utilization patterns deviate from acceptable utilization standards. Combines utilization information with quality goals and acts accordingly to ensure high quality, cost effective care is being delivered. Works collegially with Medical Leadership to identify opportunities for improved quality and cost-effectiveness.
Valid RN License
Bachelor's Degree in Nursing or health care related degree.
Three (3) years experience in a clinical setting
Five (5) years experience in the Medical Management arena, such as utilization, case management or quality improvement
Five (5) years experience in a management role for a professional clinical staff of five or more members leading or assisting in all phases of effective supervision (ie. Recruitment, performance management, training)
Experience with an accreditation process such as NCQA, JCAHO
Five (5) years experience and knowledge of HMO, PPO, TPA, PHO and Managed Care functions (e.g. accounting/finance, reinsurance, administration, medical delivery, regulatory compliance, claims processing).
Three (3) years experience in ambulatory medical management.
Case management experience
5 years experience with accreditation process, such as NCQA, JCAHO, etc.
Experience developing and presenting training materials.
Internal Number: 18-3418
About McLaren Health Plan
McLaren Health Care is a fully integrated health network, committed to quality, evidence-based patient care and cost efficiency. The McLaren system includes 12 hospitals, ambulatory surgery centers, imaging centers, freestanding dialysis centers, a regional network of cancer centers and providers, an employed primary care physician network, assisted living facilities, commercial and Medicaid HMOs, home health care and hospice, durable medical equipment and a wholly-owned medical malpractice insurance company. McLaren has 19,500 employees and more than 20,000 network physicians. The National Committee for Quality Assurance (NCQA) has awarded McLaren Health Plan's Medicaid HMO and Commercial-HMO/POS Combined products, an accreditation status of Commendable for service and clinical quality that meet NCQA's rigorous requirements for consumer protection and quality improvement.McLaren Health Plan has been awarded several Pinnacle Awards for Best Practices from the Michigan Association of Health Plans (MAHP) in a variety of categories:2003 - PCP Case Management2004 - ABAD (Assistance for the Blind and Disabled) Lets Connect2005 - Disease Management for Well Children Population2006 - Comm...unity Outreach to Prevent Lead Poisoning ("Not in My Back Yard")2007 - Chronic Disease Care2008 - You've Got a Nurse (commercial business) 2010 - Early Care Health Families2011 - MedCheck (commercial business)2012 - Taking it Off weight management program (commercial business)