The Director, Care Management Medicare and Medi-Cal Operations will report to the Senior Director of Care Management and will serve as the professional leader of registered nurses and clinical social workers within Blue Shield of California and Blue Shield Promise Health Plan care management. The ideal candidate should be a good collaborator, experienced in people leadership, and who will serve as a mentor to staff and advisor to senior leadership. The selected candidate will also function as the subject matter expert on Medicare and Medi-Cal regulations, processes for dual eligible members, Medi-Cal SPD, Medicare Advantage, and other programs and services. The director will represent care management in initiatives, client presentations, act as a liaison between other business units within Blue Shield to bolster care management knowledge on community resources, best practices, and promote holistic and integrated approach to medical care management.
Responsibilities
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
Enhancement or creation of care management processes in compliance with regulatory requirements
Maintenance and operationalizing of the Model of Care (MOC) for SNP members (DSNP and CMC)and other contracts with DHCS and CMS in close collaboration with and guidance from the Chief Medical Officer of Blue Shield Promise Health Plan and Quality Improvement department
Responsible for ensuring that the care management department readiness for government and accreditation audits
Primary involvement with committees, projects, initiatives, professional associations, and other service providers to promote appropriate and cost-effective care delivery for the population
Integrates knowledge and experience in health care delivery in managed care and population health into provider network while seeking for 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
Enhancement of nursing or social work practices that solidify staff capabilities regarding managing ongoing patient crisis intervention and customer service recovery efforts with patients and families to achieve overall patient satisfaction
Demonstrates a passion for leading positive change by enhancement and sustainment of an innovative care management program that advocates for patient safety by keeping informed of mandates, regulations, and best practice innovations
Enhancement and development of client health education, Advance Healthcare Planning and End of Life counseling and support and promotes participation in staff, patient, and community education
Promotion of best practice in impacting social determinants of health and homelessness
Promotion of continuing education and professional development
Represent Blue Shield care management in Blue Shield sponsored community events and fairs
Regular collaboration with other Blue Shield managers in care management and other business units
Maintain daily measurement standards and outcomes for staff
An active participant in practice transformation
Prepares written proposals for funding opportunities
Participate in daily huddles with Senior Director of Care Management and members of the CM leadership team
Knowledge andExperience
A minimum of 5 years ofoutpatient care management.
A minimum of a bachelor's degree in Nursing from a regionally accredited college or university, master's degree preferred
Licensure as a Registered Nurse (RN) in California
Certified Case Manager (CCM) or related board certification, i.e. ACM from a nationally recognized entity
A minimum of 6 years' progressive experience successfully managing people and leading teams
A minimum of 5 years' progressive leadership experience in Medi-Cal/Medicare care management at a health plan or similar health care organization structure
A minimum of 10 years' combined experience managing projects, programs, complex changeinitiatives, and/or CMS and DHCS audits and regulatory compliance
A minimum of 10 years' experience in developing and executing strategic business plans and budgets with a track record of achieving results
Health insurance/managed care experience (Commercial, Medicare, and Medi-Cal)
Lean methodology
Excellent presentation and procedure-writing skills
Excellent communication skills
Transitions of care
Community resources and advocacy
Practice integration in a triad model of care
Strong independent judgment, critical and analytical thinking, and problem-solving skills required
Proven ability to partner, collaborate with, and influence relevant stakeholders, both internal and external. Excellent relationship and consensus-building skills required
Ability to multi-task, prioritize, and deliver in a demanding and constantly changing corporate environment
Continuously learns and a strong emotional intelligence
Skills to document and articulate information to senior leaders is required
Must possess strong negotiation and influencing skills
Ability to work with multiple stakeholders at all levels
Builds a strong internal and external network of personal relationships to identify issues and opportunities and provides positive, best-in-class perspectives to others (e.g., executive team)
Additional Information
About Company: At Blue Shield of California we are parents, leader, students, visionaries, heroes, and providers. Everyday we come together striving to fulfill our mission, to ensure all Californians have access to high-quality health care at a sustainably affordable price. For more than 80 years, Blue Shield of California has been dedicated to transforming health care by making it more accessible, cost-effective, and customer-centric. We are a not-for-profit, independent member of the Blue Cross Blue Shield Association with 6,800 employees, more than $20 billion in annual revenue and 4.3 million members. The company has contributed more than $500 million to Blue Shield of California Foundation since 2002 to have a positive impact on California communities. Blue Shield of California is headquartered in Oakland, California with 18 additional locations including Sacramento, Los Angeles, and San Diego. We're excited to share Blue Shield of California has received awards and recognition for - LGBT diversity, quality improvement, most influential women in corporate America, Bay Area's top companies in volunteering & giving, and one of the world's most ethical companies. Here at Blue Shield of California, we're striving to make a positive change across our industry and the communities we live in - Join us!
Physical Requirements: Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day. Please click here for further physical requirement detail.
EEO Footer: External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.
