REMOTE - Medical Management Director - CSMV(Managed Care & TRICARE Experience Preferred) - R12272
CareSource Military & Veterans is dedicated to improving health care access and delivery for service members, retirees, veterans, and their families. We transform health care for the military community through care coordination and integrated programs that improve the health and well-being of our members. As a mission-driven organization, we invest resources into the communities and families we serve.
Job Summary 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.
Essential Functions
• 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.
Education and Experience
• Bachelor's degree in Healthcare Administration, Public Health, Nursing, or a related field required
• Master's degree in Healthcare Administration, Public Health, Nursing, or a related field preferred
• 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
• Five (5) years in a leadership role. preferred
• TRICARE or Veteran Affairs experience preferred
Competencies, Knowledge and Skills
• 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
Licensure and Certification
• Active, unrestricted Registered Nurse (RN) license preferred
• Certified Case Manager (CCM) preferred
• Certified Professional in Utilization Review (CPUR) preferred
• other relevant clinical certification preferred
Working Conditions
• General office environment; may be required to sit or stand for extended periods of time
• Remote capabilities
• Up to 15% (occasional) travel to attend meetings, trainings, and conferences may be required
Compensation Range
$113,000.00 - $197,700.00 CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.
Compensation Type
Salary
Competencies
• Fostering a Collaborative Workplace Culture - Cultivate Partnerships - Develop Self and Others - Drive Execution - Influence Others - Pursue Personal Excellence - Understand the Business
This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that wel
Job Summary 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.
Essential Functions
• 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.
Education and Experience
• Bachelor's degree in Healthcare Administration, Public Health, Nursing, or a related field required
• Master's degree in Healthcare Administration, Public Health, Nursing, or a related field preferred
• 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
• Five (5) years in a leadership role. preferred
• TRICARE or Veteran Affairs experience preferred
Competencies, Knowledge and Skills
• 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
Licensure and Certification
• Active, unrestricted Registered Nurse (RN) license preferred
• Certified Case Manager (CCM) preferred
• Certified Professional in Utilization Review (CPUR) preferred
• other relevant clinical certification preferred
Working Conditions
• General office environment; may be required to sit or stand for extended periods of time
• Remote capabilities
• Up to 15% (occasional) travel to attend meetings, trainings, and conferences may be required
Compensation Range
$113,000.00 - $197,700.00 CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.
Compensation Type
Salary
Competencies
• Fostering a Collaborative Workplace Culture - Cultivate Partnerships - Develop Self and Others - Drive Execution - Influence Others - Pursue Personal Excellence - Understand the Business
This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that wel