Director, Managed Care Services
- Career Level
The Director, Managed Care Services develops the strategic vision for MEMIC's medical management programs and services. Drives and reports on effective execution of all managed care services throughout the organization, in line with strategic goals. Attends to the functional operation of the Managed Care Services unit; which involves overseeing the activities and development of the Unit Managers and their teams.
- Develops and implements managed care services which include medical management, nurse case management, bill review, pharmacy benefit management and ancillary services, when necessary; that align with and compliment the organization's vision, goals, and strategy.
- Assists the VP, Claims with the development and implementation on focused Managed Care Services Best Practices targeting utilization of Nurse Case Management services; Utilization and Peer Review services; Network utilization and Utilization of Ancillary Cost Containment Programs as well as identifying expectations with vendor managed care service products.
- Develops specific statistical, data and management information reports to analyze and evaluate the effectiveness and value outcome of all Managed Care Services. Reports managed care cost containment results to the Executive Team.
- Investigates, develops, and implements new managed care savings programs as appropriate.
- Examines processes and implements policies and procedures to continually improve upon the operation of the Managed Care Services Department.
- Develops marketing materials for Claims, Underwriting, Agents, and Brokers to effectively communicate medical management products and services.
- Provides customer support to all personnel, interacting with internal and external customers to resolve Managed Care Service issues
- Assures all Managed Care Services (internal and external) are compliant with State and Federal regulations.
- Formulation of Budgets and Expense Management initiatives.
- Assists the Director of Claim Compliance on developing and implementing a Quality Assurance Program for Nurse Case Managers and Managed Care vendor services.
- Identifies training and developmental needs of managed care services team and works with Manager of Training and Development to deliver on these needs.
- Participates as needed on industry group committees and MEMICs Medical Advisory Board.
- Bachelors Degree with 3 to 5 years of mid to senior management experience within the Workers Compensation Managed Care services industry, or an equivalent combination of education and experience, required. MBA or Masters Degree beneficial.
- Degree in Nursing, Healthcare, Occupational Medicine, or Business Management beneficial.
- Knowledge regarding relationship of Managed Care Services to Workers Compensaton claim services.
- Excellent verbal, written and interpersonal communication skills a must.
- Excellent analytical and organizational skills with strong attention to detail.
- Demonstrates strong leadership skills.
- Proven ability to solve problems and make sound decision a must.
- Project Management skills a plus.
- Ability to work collaboratively with cross functional business unit to launch and implement new products and services.
- Ability to work independently and within a team environment.
- Ability to function effectively within an ever-changing environment to meet deadlines and reprioritize as necessary.
- Proficiency in MS Office (Excel, Word, Powerpoint, Project) and data warehouse utilization.