The Director, Clinical Services position is accountable for strategic execution of PMA's medical case management, utilization management, and vocational rehabilitation services. This involves setting priorities, allocating resources, and leveraging strategic partners to measurably improve claim outcomes and positively impact PMA financials. This position will provide leadership and direction for an integrated program which utilizes both internal and vended resources to deliver a high quality, cost effective program with industry leading results.
* Direct management of PMA's medical and vocational case management services; design and implement medical management and vocational rehabilitation services which align with and complement the organization's strategy, model and reputation.
* Responsible for operational leadership and direction of all aspects of the medical and vocational case management service solution, which supports and integrates with PMA's claims handling services, to include but not be limited to: clinical intervention triage, medical case management, utilization review, and vocational rehabilitation.
* Collaborate with all units within Managed Care to define an integrated solution which focuses on patient recovery, leverages data to identify cost-driving trends and continually refine, implement, and measure the impact of process and outcome improvements.
* Collaborate with various levels of Claims Operations and Client Services to identify and address opportunities for solution enhancements and/or service delivery improvements.
* Responsible for medical and vocational case management services' financial efficiency; utilize cost/benefit analysis and program evaluation to develop the operational model, staffing levels and information technology needs.
* Identify and participate in evaluation of strategic business partners for services to supplement and complement the organization's medical and vocational case management services.
* Responsible for the development of internal- and external-facing outcome metrics and management information needed to monitor and measure the quality of services and the financial and operational impact of medical and vocational case management services.
* Responsible for participating in and execution of the data strategy and data integrity related to medical and vocational case management services.
* Responsible for defining, communicating, and executing on medical and vocational case management policies, procedures, workflows, initial and ongoing training programs, and performance expectations to ensure service delivery consistency, effectiveness, and compliance with regulatory requirements and key accreditation standards.
* Responsible for directing all medical and vocational case management services activities to deliver on corporate operational and financial objectives and client outcomes.
* Support the evolution of PMAs Managed Care solution through insight into the medical and vocational case management competitive landscape, identification of medical or disability emerging trends, recommend and participate in the development and execution of new service solutions or refinement of existing solutions as it relates to medical and vocational case management solutions to ensure PMA remains competitive.
* Assist in the identification and triage of potential quality improvement issues.
* Represent PMA's Managed Care Department at customer meetings, on interdepartmental committees and through professional organizations.
* Supervise Case Management Managers. Guide and direct employee development and performance management based on objective analysis of results and trends.
* Demonstrate commitment to Company's Code of Business Conduct and Ethics, and apply knowledge of compliance policies and procedures, standards and laws applicable to job responsibilities in the performance of work
* Bachelor's Degree preferred or associate degree in nursing with evidence of continuing education in the area of medical treatment protocols as well as equivalent professional experience required.
* Current, unrestricted registered nursing license is required. CCM, CMAC, or CDMS designation is required.
* Master's in Rehab or related medical/counseling degree with CCM and CRC would be considered.
* Minimum of ten (10) years national workers' compensation experience in the field of Managed Care is required.
* Minimum five (5) years of applicable management responsibilities.
* Prior experience working collaboratively with cross-function business units to launch and implement projects, continually monitor for program performance and drive solutions for continual program evolution.
* Proven Project Management experience with the ability to work on multiple projects simultaneously and to effectively prioritize.
* Demonstrated management and leadership skills with a proven track record of successful group dynamics and interpersonal relationships.
* Proven analytical skills are required with the ability to solve complex problems.
* Effective communication skills with demonstrated interpersonal skills having the ability to influence, direct both verbally and in written communications with internal and external parties on a wide variety of issues.