JOB OBJECTIVE

Under the direction of the Medical Management Director this position is responsible for overseeing, coordination, implementation, and completion of different programs or projects impacting case management and utilization review. This position will work closely with the Director and Managers in Medical Management to ensure process is in place for compliance with regulatory requirements for medical management activities deemed by Federal, State and other regulatory and accreditation agencies.

ESSENTIAL FUNCTIONS AND RESPONSIBILITIES

The Medical Management Program Manager is responsible for performing the following duties:

• Provide training and adaptation to any new system that will be used by medical management team, i.e. QNxt
• Develops desktop procedures and workflows for any new system that will be used by medical management team
• Lead the planning and implementation of projects that are delegated or assigned by the DMM.
• Manage multiple, ongoing medical management project implementations to include the definition of project scope, goals and deliverables.
• Define project tasks and resource requirements.
• Develop and maintain detailed project plan to include milestones, tasks, and target/actual dates of completion.
• Assemble and coordinate resources needed to include logistics, agendas, and meeting.
• Plan and schedule project timelines and revise as appropriate to meet changing needs and requirements.
• Track project deliverables using appropriate tools.
• Prepare and submit project status reports to management and all stakeholders.
• Provide direction and support to team
• Implement project changes and interventions to achieve project goals
• Assist with researching case management and utilization review programs, standards, regulations
• Update relevant policy and procedures annually and as required by contracted health plan(s)or regulatory mandates
• Perform other duties as assigned including participation in all applicable committees
• Collaborate and assist Managers of UM and CM as needed
• Assist DMM to ensure compliance with regulatory requirements and application of clinical decision support criteria for case management and utilization activities deemed by Federal, State and other regulatory and accreditation agencies.
• Performs trouble-shooting when difficult situations arise and takes independent action to resolve
• Manages special projects, i.e. emergency room visit follow-up.
• Assist with coordinating delegation oversight audit requests, focus audit requests, and/or corrective action plans
• Works collaboratively with the entire organization to be in a state of continual readiness for Delegation Oversight Audits performed by health plans for various functions