Manager, Medical Management

McLaren Health Care • Flint, MI

1d • Hybrid

About The Position

McLaren Health Plan (MHP) is a company with a culture of high performance and a mission to help people live healthier and more satisfying lives. We are looking for a Manager, Medical Management to join in leading the organization forward.
MHP is a Managed Care Organization dedicated to meeting the health care needs of each member. MHP offers multiple product lines, including individual and family plans, and Medicaid and Medicare plans to Michigan residents for every stage of life. McLaren Health Plan is accredited by the National Committee for Quality Assurance (NCQA).
MHP values the talents and abilities of all our employees and seeks to foster an open, cooperative and dynamic environment in which employees and the health plan can thrive. As an employee of MHP, you will be a part of a dynamic organization that considers all our employees as leaders in driving the organization forward and delivering quality service to all our members.
Learn more about McLaren Health Plan at https://www.mclarenhealthplan.org

Position Summary:
Responsible for all aspects of the Medical Management process from the determination of the appropriateness of care to ultimately improving health outcomes. Responsible for the education, monitoring and evaluation of the Medical Management staff for all product lines. Evaluates, designs, implements and adjusts workflows to ensure accuracy and department efficiencies. Manages Medical Management processes to be appropriate; compliant with NCQA standards and regulatory agencies and within budget. Develops and implements departmental policies and procedures as well as documentation of the case management and utilization management processes. Responsible for the ongoing assessment and delivery of Health Services aspects of the Quality Improvement Performance Plan (QPIP) to facilitate that quality standards are met, with a focus on all assigned NCQA standards. Intervenes with providers when utilization patterns deviate from acceptable utilization standards. Combines utilization information with quality goals and acts accordingly to ensure high-quality, cost-effective care is being delivered. Works collegially with Medical Leadership to identify opportunities for improved quality and cost-effectiveness.
This is a hybrid position with requirements to come onsite as scheduled, Flint, MI.
This position must have experience in case management.

Requirements

• Bachelor’s Degree in Nursing, health care or business.
• Three (3) years clinical experience.
• Valid License in state doing business in.
• Five (5) years’ experience in the progressively more complex Medical Management arena in Managed Care, such as case management, utilization management and/or quality improvement (i.e. HEDIS, NCQA) with at least two (2) years in a supervisory role for professional clinical staff leading or assisting in all phases of effective supervision (i.e. Recruitment, performance management, training).
• May require weekend supervision for staff.
• This position must have experience in case management.

Nice To Haves

• Seven (7) years’ experience and knowledge of Managed Care functions (i.e., medical delivery, regulatory compliance, HEDIS, NCQA)
• Three (3) years’ experience in ambulatory medical management.

Responsibilities

• Responsible for all aspects of the Medical Management process from the determination of the appropriateness of care to ultimately improving health outcomes.
• Responsible for the education, monitoring and evaluation of the Medical Management staff for all product lines.
• Evaluates, designs, implements and adjusts workflows to ensure accuracy and department efficiencies.
• Manages Medical Management processes to be appropriate; compliant with NCQA standards and regulatory agencies and within budget.
• Develops and implements departmental policies and procedures as well as documentation of the case management and utilization management processes.
• Responsible for the ongoing assessment and delivery of Health Services aspects of the Quality Improvement Performance Plan (QPIP) to facilitate that quality standards are met, with a focus on all assigned NCQA standards.
• Intervenes with providers when utilization patterns deviate from acceptable utilization standards.
• Combines utilization information with quality goals and acts accordingly to ensure high-quality, cost-effective care is being delivered.
• Works collegially with Medical Leadership to identify opportunities for improved quality and cost-effectiveness.

What This Job Offers

• Job Type: Full-time
• Career Level: Manager
• Number of Employees: 5,001-10,000 employees