Under the direction of the Vice President of Care Management, the Clinical Director of Care Management, Well Sense is responsible and accountable for the overall strategic direction, oversight, analysis, clinical compliance and data reporting for our Medicaid as well as Medicare Advantage Members and the Dually Eligible Members. The Director ensures that the delivery of care management and related care coordination activity between Medicaid and Medicare 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.
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.
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, marking, 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
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.
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
A minimum of 7 years of progressive care management leadership experience within managed care of 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 CMS and EOHHS 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 geriatric and Medicaid/Medicare populations
Experience work with an integrated care model/use of supportive services
Experience in program development and/or health poli
Experience in managing remote and field teams.
Experience in population health management, provider-based and alternative models of care preferred.
Expertise in clinical/care management information systems such as Jiva
Experience managing teams in Medicare, Medicaid and duals program
Experience leading transitions of care programs and familiarity with community resources and advocacy programs
Certification or Conditions of Employment:
Active, unrestricted MA Registered Nurse license, required
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 proje
Excellent organizational skills
Strong independent judgment, critical and analytical thinking, and problem-solving skills required
Working Conditions and Physical Effort:
Travel within the SCO geographic network as necessary required
*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.
Telecommuting is allowed.
Internal Number: 2014253
About Well Sense Health Plan
Imagine working for an organization committed to making a difference. Founded in 1997 by Boston Medical Center (BMC), BMC HealthNet Plan supports the mission of BMC by providing medical care access to the underserved, disabled, elderly and other vulnerable populations.
BMC HealthNet Plan is a not-for-profit, market leading managed care organization that offers health insurance coverage to low-to-moderate income individuals in Massachusetts and New Hampshire (where it is known as Well Sense Health Plan). We offer health insurance plans in the Medicaid and commercial markets, and contract with health care providers and hospitals throughout Massachusetts and New Hampshire.
We employ over 600 individuals in Charlestown, Massachusetts and Manchester, New Hampshire. We offer our employees highly competitive benefits, compensation package and flexible work arrangement options. To demonstrate our commitment to serving the community, our employees are entitled to eight hours of paid volunteer time per year.
BMC HealthNet Plan employees are a diverse, talented workforce that work together to represent our values – member focus, stewardship, partnership, quality, inclusion and integrity.