Director Medical Case Manager - Western Zone

AmTrust Financial Services, a fast growing commercial insurance company, has a need for a Director of Managed Care and Clinical, for our Western Zone.
We are seeking a professional who is hungry, humble, and a strategic thinker: someone who is driven to deliver results, collaborates with authenticity and respect, and can see the bigger picture to help shape the future of the business.
PRIMARY PURPOSE: Reporting to the Head of Managed Care and Clinical, the Director of Managed Care will have responsibility for managing the performance, productivity, and medical management outcomes of AmTrust’s managed care operations. This role will have oversight of telephonic nurse case management, pharmacy management nurses and Utilization review nurses to deliver optimal claim results.
Provide leadership and guidance for field managed care operations in assigned zone.Execute medical management strategy; analyze medical management results and create annual operational goals and objectives for claim handling operation.Plan, organize, and monitor the daily activities of managed care operations in assigned zone.Ensure all Managed Care processes and protocols are effective executed.Serve as a technical and business resource for nurse case managementMonitor and analyze significant legal developments and legislative changes that may affect medical management. Collaborate with Director of Medical Strategy and Clinical Optimization to address changes.Participate in the effective selection, coaching, medical education and clinical development of nurse case managers.Manages project development/enhancements through coordination with WC operationsEmploy performance management and performance review processes to maximize performance of employees, correct performance problems, provide development opportunities and promote effective communication with employees.Ensure claim quality in accordance with best practices and company guidelines.Maintain appropriate staffing levels in conjunction with workloads.Select, train and manage staff. Plan staff responsibilities and manage activities, utilizing staff resources effectively.Ensure appropriate execution of quality assurance processes, inclusive of identification of strengths, deficiencies and implementation of action plans focused on improved results.Lead by example in effectively supervising, coaching, developing, motivating, and evaluating staff.Analyze and report on field claim activities and initiatives.Ensure regulatory compliance with jurisdictional workers' compensation rules and statutes.
QualificationsActive unrestricted RN license in a state or territory of the United States with eligibility to get and/or renew a multistate license required. Bachelor's degree in nursing (BSN) from accredited college or university or equivalent work experience preferred. Certification in case management, pharmacy, rehabilitation nursing or a related specialty is highly preferred.Seven (7) years of related experience or equivalent combination of education and experience required to include two (2) years of direct clinical care OR two (2) years of case management/utilization management required.Five + years of direct nurse management experience.
Skills & KnowledgeKnowledge of pharmaceuticals used to treat painKnowledge of behavioral healthKnowledge of pain management processKnowledge of drug rehabilitation processKnowledge of workers' compensation laws and regulationsExcellent oral and written communication,Ability to prepare presentation documents and present to senior leadershipAdvanced computer skills to include Microsoft ProductsProven ability to manage organizational change, to involve and influence others to accept new ideas or innovative approaches, to lead in a team based organizationAbility to manage a diverse team including clinical professionals in multiple locationsAbility to develop reports, metrics and improvement plansAbility to interact collaboratively and work effectively with a multi-functional team and throughout the organization; fosters an environment of shared responsibility and accountabilityExperience applying medical management treatment guidelinesExperience with writing and implementing program level policy and proceduresAnalytic and interpretive skillsStrong organizational skillsExcellent interpersonal skillsExcellent negotiation skillsAbility to work in a team environmentAbility to meet or exceed Performance CompetenciesExperience with State and external accreditation managed care audits and reviewsPrior experience developing and leading nurse case management, medical director and clinical teamsDemonstrated results in developing strategic plans and executing key initiativesAbility to collaborate across functional lines and leadersStrong communication and analytical skills