JOB SUMMARY

Responsible for the operations of the Care Management Program staff as well as oversight of the population programs under Triple S. Oversees the care coordination of all member needs including those with chronic clinical conditions. Responsible for coordination of health plan activities to the overall Care Management process, including member Health Risk Assessments, Individual Care Plans, Interdisciplinary Care Teams and other care activities, ensuring continue evaluation of members ‘care. It should work in close coordination with Delegated Entities, Internal Departments, Medical Director and other health professionals to ensure compliance and quality of services offered.

ESSENTIAL FUNCTIONS

Strategic Leadership & Financial Governance:
Oversee daily operations of the Care Management department to ensure regulatory, contractual, and quality compliance.
Assist in the development and execution of departmental work plans and strategic initiatives across the organization to ensure alignment with corporate goals and maintain Program governance.  
Ensure operational efficiency through resource allocation, process improvement, and data-driven decision-making.
Regulatory Compliance:
Maintain comprehensive policies, procedures, analysis, and documentation required for internal and external audits, supporting corrective actions as needed. 
Ensure adherence to all applicable standards and requirements established by CMS, ASES, URAC, and other regulatory bodies.
Monitor and evaluate key performance metrics, care goals, and quality outcomes, revising operational plans and internal documentation as needed to remain compliant. 
Develop and implement performance interventions and process improvements (such as the PDSA cycles) based on utilization analysis and data driven decision – making.
Partner with Medical Directors, providers and internal divisions to monitor, support, and align integrated care delivery with corporate standards. 
Clinical Program Execution:
Maintain accurate reporting, statistical analysis, and documentation for internal and external audits. Develop and implement projects aimed at improving cost-effectiveness, quality outcomes, and member satisfaction.
Participate in committees and initiatives across the organization to support strategic goals.
Assist in the development of annual work plans, program descriptions, and strategic initiatives.
Efficiency & Optimization:
Ensure overall operational efficiency through proper resources allocation, process improvement, and data – driven workflow decision – making. 
Interview, hire, train, mentor, and evaluate direct reports, ensuring staff performance aligns with departmental goals.
Provide coaching, counseling, and recognition to promote engagement and productivity.
Manage workflow, delegate tasks, and monitor staff activities to ensure effective operations.
Communicate policies, procedures, program updates, and performance metrics to staff consistently to optimize system utility and compliance. 

EDUCATION

EXPERIENCE

• Bachelor’s Degree (master’s degree, preferred) in Health Education, Nursing Sciences, Health Services Administration or other health related areas.
  Three (3) to five (5) years of experience in a related area preferably in the Health Insurance Industry.
• Current/ valid license in Health Education, Nursing or Health Services Administration without restrictions, Case Management Certification, preferable.  

LICENSES AND CERTIFICATIONS

COMPETENCIES