Medical Management Director

🔥 58 minutes ago

🦞 Maine – Remote

🦞 Maine – Remote

💵 $132.7k - $153.7k / year

⏰ Full Time

🔴 Lead

👔 Director

👻 Ghost score 0%

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Community Health Options

WebsiteLinkedInAll Job Openings

51 - 200 employees

Founded 2012

🏥 Healthcare

💼 Consulting

📦 Logistics

Healthcare • Consulting • Logistics

Community Health Options is a Maine-based health insurance provider dedicated to offering flexible and affordable health plans for individuals and families, as well as small and large groups. They focus on providing comprehensive healthcare coverage with a wide network of in-network providers, while also offering wellness programs, virtual care options, and specialized support for chronic illnesses. Their mission centers around delivering benefits designed to meet the real needs of their members, while helping to reduce out-of-pocket healthcare costs.

📋 Description

• Develop and implement strategic plans for care management, utilization management, and appeals programs • Lead and mentor a team of professionals in these areas • Collaborate with senior leadership to align departmental goals with the organization's mission and objectives • Manage program budgets and the care model under the oversight of the CMO • Oversee development and execution of care management programs to enhance member outcomes and satisfaction and reduce total costs of care • Ensure Care Management is integrated into the population health strategy • Monitor and evaluate care management performance metrics and implement improvement strategies • Manage utilization review processes to ensure appropriate resource use and adherence to clinical guidelines • Develop utilization management policies and procedures compliant with regulatory standards and payer requirements • Analyze utilization data to identify trends and opportunities for cost savings and quality improvement • Oversee appeals processes to ensure timely and accurate handling of denials and appeals • Develop and maintain appeals management policies and procedures compliant with regulatory and contractual requirements • Collaborate with clinical and operational teams to resolve complex cases and improve the appeals process • Oversee appeals vendor contracts • Ensure programs comply with federal, state, and local regulations and accreditation standards • Implement quality improvement initiatives • Stay abreast of industry trends and best practices • Work with internal and external stakeholders, including healthcare providers, payers, and regulatory agencies, to optimize care delivery and resource utilization • Foster communication and collaboration among multidisciplinary teams

🎯 Requirements

• Bachelor's Degree in related health field, preferred • Minimum of 2-3 years of Health Plan Medical Management (Utilization Management and Appeals) experience • Leadership experience • Working knowledge of human resource principles • Adherence to applicable regulatory requirements • Ability to adapt and be nimble to effectively problem-solve complex, multifaceted, and/or emotionally charged situations • Advanced Skills in Microsoft Products • Adaptability to electronic documentation system • Excellent communication, writing, analytical and problem-solving skills

🏖️ Benefits

• Competitive cash compensation • Comprehensive health plans • Generous PTO • Future focused 401k match • Flexible schedules to accommodate varying needs of our people • Professional development and training • Social and recreational programs