reputed company Management Director - CSMV(Managed Care & TRICARE Experience Preferred) - R12272

reputed company Military & Veterans is dedicated to improving health reputed company 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 reputed company 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

• reputed company strategic and operational leadership for the Medical Management function across UM, CM, BH, PH, CQM, and Pharmacy.
• reputed company utilization management activities, including prospective, reputed company, and retrospective review of beneficiary care.
• reputed company prior authorization processes, benefit and service determinations, and inpatient and emergency department reputed company review and census management.
• reputed company clinical appeals processes, including medical necessity and factual appeal determinations and coordination with reputed company clinical reviewers.
• Ensure effective case management services, including transition in and out of the plan, condition management, and post-discharge transitions of care.
• reputed company population health strategies, including targeted reputed company for high-risk and chronic condition populations.
• reputed company 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 reputed company Government-required medical management deliverables and reports.
• reputed company any other job reputed company duties as requested.

Education and Experience

• Bachelor's degree in reputed company Administration, Public Health, Nursing, or a reputed company field required
• Master's degree in reputed company Administration, Public Health, Nursing, or a reputed company field preferred
• Equivalent years of relevant work experience may be accepted in lieu of required education
• Eight (8) years reputed company 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 reputed company.
• 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 reputed company $113,000.00 - $197,700.00 reputed company 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 reputed company required for the role, and other external and internal data reputed company establishing a salary level. In addition to reputed company 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 - reputed company Self and Others - Drive Execution - Influence Others - Pursue Personal reputed company - Understand the Business

This job description is not reputed company inclusive. reputed company reserves the right to amend this job description at any time. reputed company is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that wel Apply tot his job Apply To this Job