Director, Case Management - Rn, Remote

Welcome to a team of caring and passionate people who work each day to meet the needs of our members and clients. At Health Benefits (a subsidiary of Health Care Service Corporation), you will be part of an organization committed to offering custom services to self-funded health benefits plans that manage costs – without compromising benefits – by offering innovative solutions, flexibility, transparency and customer support. This is an exciting time to join our team and enhance our culture that emphasizes caring, diversity and inclusion, mutual respect, collaboration and service to our communities.
Summary: The Director of Case Management will be primarily responsible for providing departmental leadership to the Case Management (CM) program, while also ensuring the appropriate and consistent application of Health Benefits, Inc.’s Healthcare Management Policies and Procedures on a day-to-day operational basis. He/she will serve as a liaison between the Case Management division of HCM Department and other Health Benefits’ operational areas, on both a local and regional basis.
Key Accountabilities
The Director of Case Management will lead the CM program by assuring the following:

• Leads the team of senior nurse manager and case managers to deliver an industry leading CM program performance.
• Evaluates, recommends, and implements constructive and timely changes to the CM program based on client, member and business needs as well as industry best practices.
• Responsible for ongoing assessment of staffing needs and create a business case for new staff and roles.
• Responsible for the assessment of evolving needs of talent and staff to successfully deliver on the CM program.
• Serves as a senior nurse leader to lead the CM program, including operations, results future enhancements and any issues.
• Serves as the champion for the career track, talent and skill development and professional growth of the CM team.
• Responsible for the program outcomes and preparing/executing action plans for any variances
• Provides assistance to the division head (Chief Medical Officer) in the preparation of the annual plan and budget for the program.
• Responsible for readiness of future program enhancements, continuous quality improvement of the offering and coordination with other clinical programs in the HCM division.
• Acts as a Subject Matter Expert to colleagues.
• Acts as a role model.
• Maintains a professional environment that fosters staff development and growth by facilitating education opportunities.
• Responsible for annual and ad hoc review of current program policies and procedures.
• Responsible for the oversight to ensure adherence to the annual plan and budget for the CM program.
• Makes recommendations for system/process enhancement to improve the program from case managers’ perspective.
• Provides or facilitates coaching and mentoring for the department.

Manages relationships and supports internal and external customers through the following:

• Responsible for timely delivery of results at program, client as well as member levels; including the reporting process and as needed, presentation of the report to the internal or external stakeholders.
• Leads/Participates in cross functional workgroups for the discovery, planning and implementation of new business, new clients and new initiatives for current clients in Case Management.
• Leads the resolution of issues brought by Client Services, Claims, Customer Service and other internal and external stakeholders.
• With a focus on customer service, collaborates with HCM Clinical Consultant team to manage expectations for sales, client management, and as needed, with brokers.

Leads the Quality initiatives for CM program through the following:

• Leads the design and implementation of the Quality Improvement plans and initiatives in Case Management
• Ensures a robust audit process to identify continuous quality improvement opportunities and addresses them through individual and team initiatives
• Serves on the Quality Executive Committee

Other duties as assigned by the manager.
Qualifications

• Must have an active, unrestricted Nurse License issues Welcome to a team of caring and passionate people who work each day to meet the needs of our members and clients. At Health Benefits (a subsidiary of Health Care Service Corporation), you will be part of an organization committed to offering custom services to self-funded health benefits plans that manage costs – without compromising benefits – by offering innovative solutions, flexibility, transparency and customer support. This is an exciting time to join our team and enhance our culture that emphasizes caring, diversity and inclusion, mutual respect, collaboration and service to our communities.

Summary: The Director of Clinical Review will be primarily responsible for providing departmental leadership to the Clinical Review program, while also ensuring the appropriate and consistent application of Trustmark Health Benefits, Inc.’s Healthcare Management Policies and Procedures on a day-to-day operational basis. The Clinical Review program consists of Utilization Management and Claim Medical Management units. He/she will serve as a liaison between the Clinical Review division of HCM Department and other Trustmark Health Benefits’ operational areas, on both a local and regional basis.
Responsibilities Include
The Director of Clinical Review will lead the Utilization Management (UM) and Claim Medical Management (CMM) programs by assuring the following:

• Responsible for the oversight to ensure adherence to the annual plan and budget for the Clinical Review division.
• Leads relationship management with guideline vendors
• Evaluates, recommends, and implements constructive and timely changes to the UM/CMM programs based on client, member and business needs as well as industry best practices.
• Acts as a role model.
• Responsible for ongoing assessment of staffing needs and create a business case for new staff and roles.
• Responsible for readiness of future program enhancements, continuous quality improvement of the offering and coordination with other clinical programs in the HCM division.
• Makes recommendations for system/process enhancement to improve the program from nurse reviewers’ perspective.
• Serves as the champion for the career track, talent and skill development and professional growth of the nurse reviewer team.
• Responsible for the program outcomes and preparing/executing action plans for any variances
• Serves as a senior nurse leader to lead Clinical Review’s UM and CMM programs, including operations, results future enhancements and any issues.
• Responsible for annual and ad hoc review of current program policies and procedures.
• Responsible for the assessment of evolving needs of talent and staff to successfully deliver on the UM/CMM programs.
• Provides assistance to the division head (Chief Medical Officer) in the preparation of the annual plan and budget for the program.
• Maintains a professional environment that fosters staff development and growth by facilitating education opportunities.
• Acts as a Subject Matter Expert to colleagues.
• Provides or facilitates coaching and mentoring for the department.
• Leads the team of senior nurse manager and nurse reviewers to deliver an industry leading program performance.

Leads the Quality, Regulation and Accreditation requirements for Clinical Review division through the following:

• Leads the design and implementation of the Quality Improvement plans and initiatives in UM/CMM
• Serves on the Quality Executive Committee
• Ensures a robust audit process to identify continuous quality improvement opportunities and addresses them through individual and team initiatives
• Manages the quality of services received from Independent Review Organizations (IROs)
• Ensures compliance with URAC accreditation, state regulatory and client-specific requirements

Manages relationships and supports internal and external customers through the following:

• With a focus on customer service, collaborates with HCM Clinical Consultant team to manage expectations for sales, client management, and as needed, with brokers.
• Leads the resolution of issues brought by Client Services, Claims, Customer Service and other internal and external stakeholders.
• Leads/Participates in cross functional workgroups for the discovery, planning and implementation of new business, new clients and new initiatives for current clients in UM/CMM.
• Responsible for timely delivery of results at program, client as well as member levels; including the reporting process and as needed, presentation of the report to the internal or external stakeholders.

Other duties as assigned by the Vice President, Healthcare Management.
Qualifications

• Prio Supervisory experience in a remote setting preferred.
• Managed Care experience preferred.
• Knowledge of insurance industry and plans
• Experience in client presentations.
• Must have an active, unrestricted Nurse License issues by a state or territory of the US.
• Write/create routine correspondence and reports.
• Prior Supervisory/Management experience required.
• Ability to communicate in a positive and effective manner in both oral and written communication.
• Must have a minimum of 5 years of clinical experience (medical/surgical, community health nursing, home healthcare nursing).
• Bachelor of Science in Nursing preferred.
• Read and interpret documents, criteria, instructions, and policy & procedure manuals.
• Active MCG Certification OR the ability to acquire within 18 months of hire required.

At Health Benefits, you will be part of an organization committed to offering meaningful benefits to our associates to support their life outside of work. From health and wellness benefits, 401(k) savings plan, a minimum of 15 days of paid time off, paid parental leave, disability insurance, supplemental life insurance, employee assistance program, paid holidays, new parent paid leave, tuition reimbursement, plus other incentives, we offer a robust total rewards package for full-time associates.
The compensation range for this full-time Director, Clinical Review position is between $70,900.00 and $133,129.00. The salary offered will vary depending on your job-related skills, education, knowledge, and experience. This role aligns with an annual incentive bonus plan.
All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, sex, sexual orientation, sexual identity, age, veteran or disability.
Required Skills
Required Experience