Senior Director, Care Continuum & Case Management

The Health Plan of West Virginia Inc; Wheeling (WV); On-site; USD 120,000 - 180,000; Full time

Job summary

The Health Plan of West Virginia Inc is seeking a Director of Case Management in Wheeling, WV. You will lead clinical program management for member-driven care across the care continuum, collaborating with senior clinical leaders to ensure regulatory and accreditation compliance.

Required: RN with 5+ years clinical and 2+ years in a management role; BSN or willingness to obtain within 2 years; multi-state RN license; experience in managed care; strong communication and analytical skills; CCM

Qualifications

• Registered Nurse with a minimum of 5 years clinical experience.
• At least two years of experience should be in a management capacity.
• Minimum of a Bachelor’s of Science degree in Nursing or willingness to obtain within 2 year of hire.
• Holds active and unencumbered multi-state RN license (Ohio or West Virginia).
• Minimum of five years in a managed care organization.
• Public speaking and excellent written communication skills, motivation and initiative, and ability to work independently.
• Superior work ethic.
• Experience in writing policies and procedures.
• Strong verbal, written, analytical, and interpersonal skills.
• Flexible and able to multi-task in a fast-paced environment.
• Self-starter with strong entrepreneurial skills.
• CCM certification a plus.

Responsibilities

• Oversees medical and Care Continuum operations.
• Provides direct supervision to the managers and supervisors.
• Develops and monitors training programs for care continuum staff.
• Participates on clinical services committees.
• Develops and revises care continuum processes, policies and procedures.
• Develops and enhances management reporting and metrics for productivity and outcomes.
• Ensures efficient care continuum workflows to meet objectives.
• Ensures programs comply with internal policies and CMS/NCQA requirements.
• Ensures care continuum programs meet quality outcomes (STAR, HEDIS, CCIP, QIP, PIPs).
• Responsible for annual risk assessment in medical management/behavioral health.
• Collaborates with CMO, VP Clinical Services, Director UM and AVP Population Health.
• Leads integration with provider health systems.
• Implements and monitors care continuum software.
• Provides input into criteria for care continuum programs.
• Leads NCQA-related compliance initiatives.
• Interacts with government agencies and employer groups.

Skills

Nursing experience

Management experience

Public speaking

Written communication

Policy writing

Analytical skills

Interpersonal skills

Entrepreneurial mindset

CCM certification

Education

BSN degree

Willingness to obtain within 2 years

Job description

The Health Plan of West Virginia Inc is seeking a Director of Case Management in Wheeling, WV. You will lead clinical program management for member-driven care across the care continuum, collaborating with senior clinical leaders to ensure regulatory and accreditation compliance.

Required: RN with 5+ years clinical and 2+ years in a management role; BSN or willingness to obtain within 2 years; multi-state RN license; experience in managed care; strong communication and analytical skills; CCM