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 adjust 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 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.
Valid RN License in state of Indiana.
Bachelor’s Degree in Nursing, health care or business.
Three (3) years clinical experience.
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 of five or more members leading or assisting in all phases of effective supervision (i.e. Recruitment, performance management, training).
Seven (7) years experience and knowledge of Managed Care functions (e.g, medical delivery, regulatory compliance, HEDIS, NCQA).
Three (3) years experience in ambulatory medical management.
Internal Number: 20004528
About MDwise Inc.
MDwise is your local, Indiana-based nonprofit health care company. We were founded in 1994 to help vulnerable populations needing health coverage in Indiana. Our parent organization, McLaren Health Care, is a nonprofit integrated health system who believes all Indiana families should have access to high quality health care regardless of income. Our mission is to provide high quality health care. We only take care of families in Indiana. MDwise works with the State of Indiana and Centers for Medicare and Medicaid Services to bring you the Hoosier Healthwise and Healthy Indiana Plan health insurance programs. MDwise has a large network of doctors, specialists and hospitals throughout the State of Indiana. We can help you make wise choices about your health, the health of your family and choosing a medical home. MDwise takes pride in providing Indiana families with quality and affordable health coverage for the whole family. MDwise is accredited by a national organization that measures the quality of health care. It is called the National Committee for Quality Assurance (NCQA). MDwise was rated 3.5 out of 5 among health insurance plans in the National Committee for Quality Assurance (NCQA)’s Medicaid Health Insurance Plan Ratings for 2019-2020.