Memorial Hermann is where you belong.
Manager, Medical Management Health Plan
At Memorial Hermann, we’re about creating exceptional experiences for both our patients and our employees. Our goal is to provide opportunities for our diverse employee population that develop and grow careers in a team-oriented environment focused on patient care.
Every employee, at every level, begins their journey at Memorial Hermann learning about the history of the organization and its established culture built on trust and integrity. Our employees drive this culture, and we want you to be a part of it.
Job SummaryThe Manager of Medical Management is responsible for the day-to-day operations of the Medical Management Department, including oversight of the health plans utilization review and case management areas. This position is responsible for providing leadership, direction, and training to staff regarding utilization review and case management policies and procedures. The Manager of Medical Management will also monitor and appraise employee performance and communicate to the employee accordingly, as well as assist the director with various administrative functions. This position reports directly to the Director of Medical Management.
Education: Bachelors of Nursing or equivalent academic credits, clinical education, and experience required
Licenses/Certifications: Current, unrestricted State of Texas RN Licensure required; Certified Case Management certification preferred
Experience / Knowledge / Skills:
- Minimum of five (5) years in healthcare (hospital or patient care setting) with at least three (3) of those years in utilization review/case management experience
- Knowledgeable and compliant with all relevant laws, rules regulations and accreditation standards and requirement
- Effective oral and written communication skills; ability to manage multiple projects independently
- Advanced knowledge of computer systems/programs, particularly Milliman Care Guidelines, MS Word, Excel and/or Access.Knowledge of insurance terminology, ICD-9/10, and CPT coding
- Demonstrates commitment to the Partners-in-Caring process by integrating our culture in all internal and external customer interactions; delivers on our brand promise of “we advance health” through innovation, accountability, empowerment, collaboration, compassion and results while ensuring one Memorial Hermann.
- Manages staff appropriately, providing oversight and management of day-to-day operations.
- Monitors all aspects of the case management process ensuring case managers adhere to documented policies and procedures.
- Develops staffing plans and supervises assigned personnel to meet department objectives.
- Establishes goals/objectives and trains, monitors, and evaluates staff as appropriate.
- Assists in the development of departmental policy and procedure manual, working in collaboration with Customer Service, Network Management, Claims, Quality Improvement, Sales, and Marketing.
- Interfaces with internal and external customers in a professional and responsible manner to enhance relationships, minimizing conflicts as validated by complaints/feedback and management observation.
- Works with the Medical Director to review and develop standards of care as identified through the case management process.
- Assists in the development of reports to monitor staff compliance with state and federal regulatory requirements.
- Participates in departmental personnel functions (hiring, counseling, firing, etc.) in conjunction with the Director of Medical Management.
- Communicates, collaborates and cooperates with internal and external stakeholders.
- Adheres to all Compliance/Program Integrity requirements.
- Complies with HIPAA Regulations
- Ensures safe care to patients, staff and visitors; adheres to all Memorial Hermann policies, procedures, and standards within budgetary specifications including time management, supply management, productivity and quality of service.
- Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency; supports department-based goals which contribute to the success of the organization; serves as preceptor, mentor and resource to less experienced staff.
- Other duties as assigned.
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