Director of Medical Management in Las Vegas

OVERALL JOB PURPOSE

Responsible for the supervision and overseeing the Medical Management departments and staff.

MINIMUM JOB QUALIFICATIONS AND REQUIREMENTS

RN with current, unrestricted license in the state of Nevada.

Bachelor’s degree in nursing or healthcare industry.

Certification in case management preferred.

Five years in a professional setting such as hospital or home health environment.

Minimum of five years actual work experience related to case management, utilization

management, quality assurance, discharge planning or other cost management program.

ESSENTIAL JOB DUTIES AND RESPONSIBILITIES

Responsible for quality and continuous improvement within the job scope.

Responsible for all actions/responsibilities as described in company controlled documentation for

this position.

Contributes to and supports the corporation’s quality initiatives by encouraging team and

individual contributions toward the corporation’s quality improvement efforts.

Evaluates the day to day activities of the medical management departments;

Assist in education of the Medical Services Personnel and acts as resource professional;

Participates in UM/QA Committee and conducts required related functions;

Supports and participates in the UM/QA plan and Committee.

Work with other departments in a cooperative manner to achieve company goals, i.e., Prior

authorization, Concurrent review, Quality Improvement, claims, Client services managers, Reinsurance

or Stop-loss carriers, Network Services, Member Services and Administration;

Participate in developing and providing input in department policies and procedures;

Supervises and participates in the case management process (Identifying members for case

management, identifying alternative resources for the referrals, negotiates rate when member is

out of network) with health plan;

Participates in CQI of Case Management Department;

Provides input on system issues and enhancements;

Investigates alternative resources for members;

Assists nurses in developing contacts and relationships with IPN, PacifiCare and other clients;

Assists nurses in developing contacts and relationships with providers, provider’s office staff and

ancillary facilities personnel;

Responsible to help oversee the HRCM screening process;

Develops a working knowledge of contracts with facilities and alternative care providers as well

as Medicare and managed care organizations, benefits and contracts.

Works with the Medical Directors by notifying managers, specialists and primary care physicians.

All other duties assigned