Director Care Management Strategy and Operations - Medicaid

Company :

Job Description :

JOB SUMMARY

This job is a strategic leadership role responsible for the development, implementation, and oversight of the portfolio of markets and segments associated with comprehensive care management, disease management, and clinical programs. This position requires sophisticated understanding of care management principles, strategic vision over the next 1-3 years for care management, operational efficiency, regulatory compliance, and financial performance. The individual will lead and develop high-performing teams, ensuring the delivery of high quality, cost-effective care that improves member and provider outcomes, and enhances overall satisfaction within these domains. The successful candidate possesses strong clinical expertise, strong analytical skills, demonstrated financial acumen, and demonstrated experience building, maintaining, and enhancing effective relationships with internal and external stakeholders.

This role can be hybrid or remote. If you are within 50 miles of an office you are required to be onsite 3 days a week. T, W, Th.

ESSENTIAL RESPONSIBILITIES

• Strategic Planning and Program Development: Develop and implement strategic and operational plans, including budget development and management, for designated service line(s), aligning with organizational goals and market trends. This includes forecasting future needs, appropriate staffing models and plans, identifying new program opportunities, and ensuring that programs remain relevant and competitive in a dynamic healthcare market. Continuously monitor and adapt the plans based on performance, regulatory changes, and emerging best practices.
• Perform management responsibilities to include, but not limited to: involved in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity. Plan, organize, staff, and manage the day-to-day operations of the team; develop and implement policies and programs as necessary; manage to assigned budgets.
• Operational Management & Process Improvement: Oversee the day-to-day operations of the care management team(s), ensuring effective resource allocation and efficient service delivery. Implement robust quality control systems and processes. Actively identify and lead process improvement initiatives focused on quality, utilization, cost containment, and enhanced member clinical outcomes. Leverage data analysis to support decisions.
• Clinical Program Oversight and Quality Assurance: Ensure the delivery of high-quality clinical care management programs, including disease management, health coaching, care coordination, and member outreach. Monitor and maintain compliance with clinical guidelines, quality metrics, best practices, and all applicable regulatory requirements (CMS, URAC, NCQA, etc.). Oversee the implementation of innovative disease management and preventative health programs.
• Stakeholder Management: Cultivate and maintain effective relationships with internal and external stakeholders, including physicians, hospitals, community organizations, regulatory bodies, sales, and market leadership, to optimize collaboration and efficient care delivery.
• Performance Measurement & Reporting: Develop and monitor Key Performance Indicators (KPIs) to assess program effectiveness. Regularly report on program progress, including clinical, financial, and operational outcomes to leadership. Utilize predictive modeling to proactively identify at-risk members and improve engagement strategies.
• Other duties as assigned or requested.

EXPERIENCE

Required

• 7 years of experience in a healthcare setting
• 7 years of experience with the designated service line (Medicaid, DSNP) in a multi-market and/or multi-segment environment
• 5 years in a Management or leadership role
• 5 years of experience with diverse populations and care delivery models

Preferred

• 5 years of strategic leadership and oversight of Managed Long Term Services and Supports (MLTSS)
• 5 years of oversight and responsibility of Dual Special Needs Plans (DSNP) leading and managing this population and product

SKILLS

• Demonstrated strategic planning, operational management, and leadership abilities
• Strong analytical skills
• Proven ability to manage budgets, personnel, staffing models, and resources effectively
• Exceptional communication and interpersonal skills
• Deep understanding of healthcare regulatory environments, and quality metrics
• Ability to develop and implement effective program evaluations and reporting systems
• Proficiency with performance improvement methodologies

EDUCATION

Required

• Bachelor’s degree in Nursing, Social Work, Business, Healthcare Administration, or related field or relevant experience and/or education as determined by the company in lieu of bachelor's degree.

Preferred

• Masters Degree in Nursing, Social Work, Business, Healthcare Administration, or related field

LICENSES or CERTIFICATIONS

Required

• Current State RN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC) or Licensed Social Worker

Preferred

• Certified Case Manager (CCM)

Language (Other than English):

• None

Travel Required:

• 25% - 50%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

• Hybrid or Remote Position

Physical work site required

• Occasionally

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy.

Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

Pay Range Minimum:

Pay Range Maximum:

Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.

California Consumer Privacy Act Employees, Contractors, and Applicants Notice

About Us

Highmark Health is a national, blended health organization that includes one of America’s largest Blue Cross Blue Shield insurers and a growing regional hospital and physician network.

Based in Pittsburgh, Pa., Highmark Health’s 35,000 employees serve millions of customers nationwide through the nonprofit organization’s affiliated businesses, which include Highmark Inc., Allegheny Health Network, HM Insurance Group, United Concordia Dental, HM Health Solutions and HM Home & Community Services.

Highmark Health’s businesses proudly serve a broad spectrum of health-related needs including health insurance, health care delivery, population health management, dental solutions, reinsurance solutions, and innovative, technology solutions.