Medical Management Director - CSMV(Managed Care & TRICARE Experience Preferred)

CareSource•Dayton, OH

1d•Hybrid

About The Position

CareSource Military & Veterans (CSMV) is dedicated to improving health care access and delivery for veterans and military families in service to our nation. The Medical Management Director - CSMV is responsible for leading CareSource Military & Veterans' integrated medical management model, including Utilization Management (UM), Case Management (CM), Behavioral Health (BH), Population Health (PH), Clinical Quality Management (CQM), and Pharmacy Management. This role ensures day-to-day operational compliance with TRICARE requirements and reporting obligations, drives high-quality and cost-effective care, reduces unwarranted variation and waste, and supports reduction in Total Cost of Care (TCOC) for the TRICARE Prime Competitive Plans Demonstration.

Requirements

Bachelor's degree in Healthcare Administration, Public Health, Nursing, or a related field required
Equivalent years of relevant work experience may be accepted in lieu of required education
Eight (8) years progressive experience in medical management, utilization management, or managed care clinical operations. required
Strong written, verbal, and executive-level communication skills.
Ability to manage competing priorities and deadlines in a fast-paced environment.
High level of professional judgment, accountability, and integrity.
Demonstrated ability to collaborate and influence cross-functionally

Nice To Haves

Master's degree in Healthcare Administration, Public Health, Nursing, or a related field preferred
Five (5) years in a leadership role. preferred
TRICARE or Veteran Affairs experience preferred
Active, unrestricted Registered Nurse (RN) license preferred
Certified Case Manager (CCM) preferred
Certified Professional in Utilization Review (CPUR) preferred
other relevant clinical certification preferred

Responsibilities

Provide strategic and operational leadership for the Medical Management function across UM, CM, BH, PH, CQM, and Pharmacy.
Oversee utilization management activities, including prospective, concurrent, and retrospective review of beneficiary care.
Oversee prior authorization processes, benefit and service determinations, and inpatient and emergency department concurrent review and census management.
Oversee clinical appeals processes, including medical necessity and factual appeal determinations and coordination with qualified clinical reviewers.
Ensure effective case management services, including transition in and out of the plan, condition management, and post-discharge transitions of care.
Lead population health strategies, including targeted outreach for high-risk and chronic condition populations.
Oversee behavioral health integration and coordination with medical and case management operations.
Ensure compliance, performance monitoring, and reporting for clinical quality and pharmacy management programs.
Ensure timely and accurate completion of all Government-required medical management deliverables and reports.
Perform any other job related duties as requested.