Director Care Management Strategy and Operations - Medicaid

Highmark Health•PA, Working at Home - Pennsylvania, PA

1d•$142,000 - $236,000•Hybrid

About The Position

This strategic leadership role is responsible for developing, implementing, and overseeing a portfolio of markets and segments involving comprehensive care management, disease management, and clinical programs. The Director provides a 1–3-year strategic vision for care management and oversees operational efficiency, regulatory compliance, and financial performance. The role leads and develops high-performing teams to deliver high-quality, cost-effective care that improves member and provider outcomes and overall satisfaction. It requires clinical expertise, analytical skills, financial acumen, and the ability to build and maintain effective internal and external stakeholder relationships. The position may be hybrid or remote. Employees who live within 50 miles of an office are required to work onsite three days per week: Tuesday, Wednesday, and Thursday. Travel is required 25%–50%.

Requirements

At least 7 years of experience in a healthcare setting.
At least 7 years of experience with the designated service line (Medicaid, DSNP) in a multi-market and/or multi-segment environment.
At least 5 years in a management or leadership role.
At least 5 years of experience with diverse populations and care delivery models.
Demonstrated strategic planning, operational management, and leadership abilities.
Strong analytical skills.
Ability to manage budgets, personnel, staffing models, and resources effectively.
Exceptional communication and interpersonal skills.
Deep understanding of healthcare regulatory environments and quality metrics.
Ability to develop and implement effective program evaluations and reporting systems.
Proficiency with performance improvement methodologies.
Bachelor’s degree in Nursing, Social Work, Business, Healthcare Administration, or a related field, or relevant experience and/or education as determined by the company in lieu of a bachelor’s degree.
Current state RN licensure, current multistate licensure through the enhanced Nurse Licensure Compact (eNLC), or Licensed Social Worker.

Nice To Haves

At least 5 years of strategic leadership and oversight of Managed Long Term Services and Supports (MLTSS).
At least 5 years of oversight and responsibility for Dual Special Needs Plans (DSNP), leading and managing this population and product.
Master’s degree in Nursing, Social Work, Business, Healthcare Administration, or a related field.
Certified Case Manager (CCM).

Responsibilities

Develop and implement strategic and operational plans for designated service lines, including developing and managing budgets and aligning plans with organizational goals and market trends.
Forecast future needs, determine staffing models and plans, identify program opportunities, and adapt plans based on performance, regulatory changes, and emerging best practices.
Make hiring and termination decisions; coach and develop employees; manage rewards and recognition, performance, and productivity; and plan, organize, staff, and oversee day-to-day team operations.
Develop and implement policies and programs as needed and manage assigned budgets.
Oversee care management team operations, resource allocation, and service delivery; implement quality-control systems and lead process improvements focused on quality, utilization, cost containment, and clinical outcomes.
Use data analysis to support operational and program decisions.
Oversee clinical care management programs, including disease management, health coaching, care coordination, and member outreach.
Monitor compliance with clinical guidelines, quality metrics, best practices, and applicable requirements, including CMS, URAC, and NCQA requirements.
Oversee the implementation of disease management and preventative health programs.
Develop and maintain relationships with physicians, hospitals, community organizations, regulatory bodies, sales, and market leadership.
Develop and monitor KPIs, report clinical, financial, and operational outcomes to leadership, and use predictive modeling to identify at-risk members and improve engagement strategies.
Perform other duties as assigned or requested.