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    Clinical Director Of Care Management

    Wellsense Health Plan
    7+ years
    Not Disclosed
    Remote, USA
    10 Dec. 5, 2024
    Job Description
    Job Type: Full Time Remote Education: BSN/MPH Skills: Causality Assessment, Clinical SAS Programming, Communication Skills, CPC Certified, GCP guidelines, ICD-10 CM Codes, CPT-Codes, HCPCS Codes, ICD-10 CM, CPT, HCPCS Coding, ICH guidelines, ICSR Case Processing, Interpersonal Skill, Labelling Assessment, MedDRA Coding, Medical Billing, Medical Coding, Medical Terminology, Narrative Writing, Research & Development, Technical Skill, Triage of ICSRs, WHO DD Coding

    Clinical Director of Care Management

    Location: Remote (United States)

    About WellSense Health Plan:
    WellSense Health Plan is a nonprofit health insurance organization serving over 740,000 members across Massachusetts and New Hampshire through Medicaid, Medicare, and Individual & Family plans. With a legacy of 25+ years, we are committed to delivering high-quality, inclusive care that meets the diverse needs of our members.

    Job Summary:
    Reporting to the Vice President of Care Management, the Clinical Director of Care Management is responsible for the strategic oversight, compliance, and execution of care management programs for Medicaid, Medicare Advantage, and Dually Eligible Members. This role drives innovation, ensures quality, and maintains compliance with regulatory and contractual standards. The Clinical Director represents the organization in external meetings with key stakeholders, including regulators and advocates.

    Key Responsibilities

    • Care Management Optimization:

      • Lead the development of nursing, social work, and behavioral health practices to deliver high-quality, cost-effective, and member-centric care.
      • Manage member crises and recovery while collaborating with community partners and pharmacy services.

    • Innovation & Education:

      • Implement innovative care management strategies, keeping teams informed of best practices and regulatory updates.
      • Enhance member education on self-management, disease management, and end-of-life care.

    • Social Determinants & Holistic Care:

      • Establish frameworks addressing social determinants of health and homelessness.
      • Oversee care planning for members with complex health and socioeconomic needs.

    • Compliance & Reporting:

      • Ensure regulatory compliance and develop standardized workflows for accurate reporting.
      • Collaborate with Quality Improvement teams to achieve performance targets and quality goals.

    • Team Leadership:

      • Promote professional development and continuing education for staff.
      • Balance workloads and oversee staffing adequacy to meet organizational goals.

    • Stakeholder Collaboration:

      • Partner with internal and external stakeholders to support care management programs and ensure effective communication.

    Qualifications

    Education:

    • Bachelor’s Degree in Nursing (required).
    • Master’s Degree in Nursing, Public Health, or related field (preferred).
    • Graduate of an accredited nursing program.

    Experience:

    • 7+ years in progressive care management leadership roles within managed care.
    • Proven experience leading teams and managing complex initiatives in Medicaid/Medicare programs.
    • Expertise in data-driven decision-making, regulatory compliance, and strategic planning.
    • Experience working with geriatric, Medicaid/Medicare populations, and integrated care models.
    • Familiarity with population health management and community resources.

    Preferred Experience:

    • Proficiency in care management systems such as Jiva.
    • Leading transitions of care programs and advocacy initiatives.
    • Managing remote and field-based teams.

    Licensure & Certification:

    • Active, unrestricted RN license in Massachusetts (required).
    • Certification in Case Management (CCM) (preferred).

    Skills & Competencies

    • Strong critical thinking, problem-solving, and organizational skills.
    • Proficient in leveraging analytics and metrics for program evaluation and improvement.
    • Exceptional relationship-building and collaboration skills across diverse stakeholders.
    • Excellent communication and presentation abilities.
    • Ability to adapt to a dynamic, fast-paced environment and prioritize multiple tasks effectively.

    Why Join WellSense?

    • Remote Work Flexibility: Enjoy full-time remote opportunities.
    • Competitive Benefits: Comprehensive salary and benefits package.
    • Commitment to Inclusion: We value diversity in both our staff and member base.

    Working Conditions:

    • Travel within the geographic network as needed.

    Equal Opportunity Employer:
    WellSense is committed to fostering an inclusive workplace. Qualified candidates are encouraged to apply, regardless of race, gender, religion, or disability status.

    Beware of Employment Scams:
    Applications are accepted only through our official website. For tips on avoiding scams, visit the FTC website.

    Apply Today:
    Join a team that’s dedicated to improving healthcare outcomes for all. Visit WellSense Careers to apply.

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