Medical Management Director – Managed Care, TRICARE Experience Preferred

Job Description

Lead the strategic direction and operational execution of the Medical Management function, encompassing Utilization Management (UM), Case Management (CM), Behavioral Health (BH), Population Health (PH), Clinical Quality Management (CQM), and Pharmacy services. Oversee and optimize utilization management activities, with a focus on streamlining prior authorization processes and ensuring efficient resource allocation. Implement and enhance effective case management services, with a particular emphasis on seamless transition management for members. Drive the development and execution of comprehensive population health strategies, integrating behavioral health services to address holistic member needs. Ensure strict adherence to clinical quality standards and pharmacy management programs, maintaining compliance with regulatory requirements and promoting best practices.

Qualifications

1. Bachelor's degree in Healthcare Administration, Public Health, Nursing, or a related field is essential. 2. A Master's degree in Healthcare Administration, Public Health, Nursing, or a related field is highly desirable. 3. Possess eight (8) years of progressive experience in medical management, utilization management, or managed care clinical operations. 4. A minimum of five (5) years in a leadership capacity is preferred. 5. Familiarity with TRICARE or Veteran Affairs programs is advantageous.

Benefits

- Health insurance coverage. - Participation in a 401(k) retirement plan. - Generous paid time off benefits. - Remote work possibilities. - Opportunities for professional development and advancement.