Director II Medical Management

Elevance Health•Washington, DC

4d•$170,384 - $255,576•Hybrid

About The Position

Director II Medical Management Location: This role requires associates to be in-office 4 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. The Director II Medical Management is responsible for the development, implementation, and oversight of integrated Medical Management of more than one member population type with varying degrees of medical complexity. How you make an impact: Directs and provides leadership for designing, developing, and implementing integrated medical management program to meet the demographic and epidemiological needs of the populations serviced. Oversees case and utilization management execution/decision making for managed member populations. Accountable to plan executive or executive team member dependent on plan size/complexity and is involved in the development of the strategic vision, goals, and objectives for medical management. Serves as liaison to state regulatory agencies. Partners with other health plan/corporate leaders to develop and deliver innovative care management services, root cause analyses and solutions to achieve quality outcomes. Directs Healthcare Management Program including disease management, case management, and utilization management. Partners with Provider Relations, Quality Management, Health Promotions, and Community Relations to develop and implement effective provider communications, quality assurance, and member outreach programs. Provides expert consultation to local plan staff on benefits interpretation and utilization and quality management matters. Ensures support for compliance with National Committee for Quality Assurance (NCQA) and assures compliance with state/and or federal program requirements. Hires, trains, coaches, counsels, and evaluates performance of direct reports.

Requirements

Requires a BA/BS degree in a health care field and a minimum of 10 years clinical work experience including prior management experience; or any combination of education and experience which would provide an equivalent background.
Previous experience with NCQA accreditation and HEDIS reporting required.

Nice To Haves

RN, LCSW, or LPC strongly preferred.
MS/MA degree in a health care field or MBA with Health Care concentration preferred.
5 or more years case management and utilization management review experience strongly preferred.
Extensive experience leading and managing teams strongly preferred.

Responsibilities

Directs and provides leadership for designing, developing, and implementing integrated medical management program to meet the demographic and epidemiological needs of the populations serviced.
Oversees case and utilization management execution/decision making for managed member populations.
Accountable to plan executive or executive team member dependent on plan size/complexity and is involved in the development of the strategic vision, goals, and objectives for medical management.
Serves as liaison to state regulatory agencies.
Partners with other health plan/corporate leaders to develop and deliver innovative care management services, root cause analyses and solutions to achieve quality outcomes.
Directs Healthcare Management Program including disease management, case management, and utilization management.
Partners with Provider Relations, Quality Management, Health Promotions, and Community Relations to develop and implement effective provider communications, quality assurance, and member outreach programs.
Provides expert consultation to local plan staff on benefits interpretation and utilization and quality management matters.
Ensures support for compliance with National Committee for Quality Assurance (NCQA) and assures compliance with state/and or federal program requirements.
Hires, trains, coaches, counsels, and evaluates performance of direct reports.