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 in state of Michigan.
Bachelor’s Degree in Nursing, health care or business.
Three (3) years clinical experience.
Five (5) years experience in the progressively more complex Medical Management arena in Managed Care, such as case management, utilization management and/or quality improvement (i.e. HEDIS, NCQA) with at least two (2) years in a supervisory role for professional clinical staff of five or more members leading or assisting in all phases of effective supervision (i.e. Recruitment, performance management, training).
Seven (7) years experience and knowledge of Managed Care functions (e.g, medical delivery, regulatory compliance, HEDIS, NCQA).
Three (3) years experience in ambulatory medical management.
Internal Number: 20003997
About McLaren Health Plan
McLaren Health Care, headquartered in Grand Blanc, Michigan, is a fully integrated health network committed to quality, evidence-based patient care and cost efficiency. The McLaren system includes 14 hospitals, ambulatory surgery centers, imaging centers, a 490-member employed primary and specialty care physician network, commercial and Medicaid HMOs covering more than 588,000 lives in Michigan and Indiana, home health and hospice providers, retail medical equipment showrooms, pharmacy services, and a wholly owned medical malpractice insurance company.
McLaren operates Michigan’s largest network of cancer centers and providers, anchored by the Barbara Ann Karmanos Cancer Institute, one of only 51 National Cancer Institute-designated comprehensive cancer centers in the U.S. McLaren has 20,205 employees and more than 85,500 network providers. Its operations are housed in more than 350 facilities serving Michigan and Indiana.
McLaren Health Plan (MHP) has been operating as a Michigan-based licensed Health Maintenance Organization (HMO) since 1998 and today delivers health care benefits to 260,000 members. The HMO was started to serve Michigan’s Medicaid population and has ad...ded group, individual and Medicare products along with a Third Party Administrator called Health Advantage, Inc., for self-funded employer groups. In 2015, MHP was awarded the right to operate in and service every county in the lower peninsula of the state of Michigan – the only provider-owned health plan to achieve this designation by the Michigan Department of Community Health. MHP has earned the prestigious Pinnacle Award every year since 2013 from the Michigan Association of Health Plans and is also accredited by the National Committee for Quality Assurance (NCQA).