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TPA VP Managed Care

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General Description:  Manages activities of the managed care department of the  TPA (FutureComp).  This includes medical case specialists who are responsible for workers compensation and disability claims case management and utilization review, including case management of medical aspects of workers compensation and disability claims and gathering demographic and clinical information on inpatient admissions and outpatient treatment, certifying the medical necessity of the services and assigning appropriate length of stay and other treatment plans.  Manages staff, provides direction, sets goals, evaluates results and ensures that overall department goals are attained.  Ensures that ongoing activities are performed according to established policies and procedures as well as applicable state regulations and specific carrier and client instructions. Ensures that own work, as well as work of any employees supervised, is in compliance with applicable laws, regulations and guidelines.

 

Responsibilities:

  • Manages activities of TPA medical case specialists responsible for workers compensation and disability claims case management and utilization review according to established policies and procedures and applicable legal and regulatory guidelines.

  • Manages staff directly and through subordinate supervisors, providing direction, setting goals, evaluating results and ensuring that overall department goals are attained.  Provides leadership, coaching, counseling, training and guidance to staff and assigns responsibilities.  Develops, assigns and monitors plans to ensure completion of goals and objectives and meeting deadlines.  Ensures new staff members are trained in department policies, practices and procedures.

  • Develops department policies and procedures in coordination with division management, including protocols and standards for case management services and utilization review; ensures adherence to policies, procedures, standards and guidelines.  Coordinates department compliance with overall division guidelines as well as regulatory agencies.  Manages development and maintenance of procedures manual.  Assists with development and administration of department budget.

  • Manages ongoing managed care activities, including case management of medical aspects of workers compensation and disability claims for TPA accounts by coordinating with patients, physicians, other health care providers and employers to facilitate positive patient outcomes, timely return to work if applicable and efficient claims resolution and utilization review, gathering demographic and clinical information on inpatient admissions and outpatient treatment, certifying the medical necessity of the services and assigning appropriate length of stay and other treatment plans.  Presents case management and utilization review information and overviews to prospects and clients as needed.

  • Assists staff with complex aspects of work as necessary.  Resolves escalated issues and problems by conferring with staff, management, other internal departments, outside contacts and clients as necessary.  Performs case management and other activities personally as workload requires.  Co-signs casework submitted by staff as required.  Responds to requests from insurance carriers, medical personnel, attorneys and others.

  • Coordinates scheduling and assignment of work and other activities to ensure that key deliverables meet established guidelines.  Assesses internal and external customer needs and manages activities to ensure services are delivered in the most efficient way possible.

  • Coordinates department technology support.  Monitors performance of systems and communicates feedback to division management, internal technology personnel and directly to vendors as appropriate.  Integrates new systems and upgrades into department operations as needed.

  • Reviews and evaluates department activities on a regular basis, ensuring that established policies and procedures are being followed.  Ensures ongoing department communications with sales, claims and management as well as other Company departments to exchange account and other information.  Provides management with regular updates on department performance; takes corrective action as necessary.

  • Maintains knowledge of current developments in the managed care industry, including regulatory issues and guidelines and technology changes; evaluates the impact of current trends and events on department activities, alerts staff to developments and develops recommendations for consideration with division management in reviewing policies and procedures.  Shares information with staff as appropriate.

  • Participates in civic activities to promote growth and development of the community and a positive image for the Company.

  • Participates in special projects and performs additional duties as required.

  • Contributes to a positive, ethical and respectful working environment and communicates openly with others.  Models Company culture both internally and externally.

 

Knowledge, Skills and Abilities:

- 4-year nursing degree or the equivalent combination of education and work experience required.  Masters degree in business, healthcare or other related field preferred.
- A minimum of 10 years workers' compensation and disability case management experience required.
- Excellent understanding of managed care industry practices, including medical case management, utilization review and related legal and regulatory guidelines.
- Strong clinical background in orthopedics, neurology or rehabilitation.
- Management skills, with ability to coach, train and motivate staff effectively.

- Supervisory experience required.

- Highly organized, with ability to manage work involving large client volume.

- Project management skills.

- Strong understanding of managed care technology applications.

- Excellent communication skills, both verbal and written.

- CCM, CRS or CDMS certification required.

- State licensing in jursdication handled

- Superior written and oral communication skills.

- Ability to work well in a team environment.

- Must have strong analytical thinking and problem-solving skills.

- Strong organizational skills required.

- Strong negotiation skills required.

 

Physical Demands:


Work is performed in a climate controlled office environment with minimal noise and limited to no exposure to chemicals or toxins.  Employees operate office equipment including; telephone - headset, Computer, computer monitors, keyboard, mouse, copier, scanner and mail machine.  Physical tasks of job include; walking, sitting, standing and bending.

 

Analysis of Physical Demands:

  • Constantly (over 66% of time) work performed requires employees to use repetitive hand motions such as typing, using a keyboard, and sitting at a desk.

  • Frequently (34%-66% of time) work performed requires employees to handle and grasp things, walk on normal surfaces, stand and bend.

  • Occasionally (1%-33% of time) work performed requires employees to drive to client appointments, have repetitive foot movements, walk on uneven or slippery surfaces to and from work and occasionally reach outward to grab things and bend.

  • Rarely  (< than 1 hour per week) work performed  requires Lifting/Carrying  items that range from 10-50lbs, pushing/pulling  items that range from 10-50lbs,  twisting/ turning including reaching over shoulder or above head , kneeling or squatting.

Job ID:

18443

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