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Director of Managed Care
Job Code:2019-02-012
Department:Business Office
FT/PT Status:Regular Full Time
Salary Minimum105,273
Salary Midpoint131,591
Position Closes:
Open Until Filled 

Job Responsibilities & Qualifications:

Primary Function
The Director will report to the Chief Executive Officer (CEO) of the Cherokee Indian Hospital Authority (CIHA).   The Director, under the leadership of the CEO, and following a matrix team model, this position will be responsible for the management, development, day to day direction, and oversight of the Tribal Managed Care, which is a division of the Hospital Authority.  The Director will ensure that the Tribal Managed Care develops, refines, and maintains all of the medical/clinical, administrative, financial, quality improvement, compliance, healthcare information technology, provider network management, member services and risk management infrastructure and functions necessary to ensure high quality integrated healthcare for plan enrollees.   

Job Description
As a member of the Executive Leadership team, the position must work collaboratively with other members to ensure maximum performance and accountability with the Tribal Managed Care.  The organizational structure utilizes a matrix management approach that requires cross functional responsibilities and accountability across the organization.  Although direct responsibility of management and oversight may not reside with the Tribal Managed Care Director, accountability for Tribal Managed Care performance will.  Areas of responsibility include medical/clinical, administrative, financial, quality improvement, compliance, healthcare information technology, provider network management, member services and risk management infrastructure, and evidence-based practice, as pertains to managed care and supporting CIHA.  


Outline of Responsibilities


In partnership with the CEO and Leadership team, ensures that the guiding vision, mission and values are incorporated into development and operations of the Tribal Managed Care and serves as a foundation for organizational direction, growth, culture, resource allocation and service management.  The Tribal Managed Care, a Medicaid managed care model, should interface with other CIHA administrative and clinical model(s) as applicable including but not limited to medical, behavioral, pharmacy and ancillary benefit services management, claims payment, provider development and contracting, utilization and vendor management. 

Develops in collaboration with other leadership members, statistical, data and management information reports to analyze and evaluate effectiveness and value outcome of all managed care services.  

Educate the Tribal leaders, the community, and key stakeholders on the mission and functions of the Tribal Managed Care.

Educates Tribal leaders and officials at the federal and state level regarding the impact of rules, requirements, and funding arrangements on the mission of the organization and the lives of enrolled members.

With staff, CIHA leadership and key stakeholders, develops and implements annual and long-term strategic plans that advance the mission of the organization, inclusive of the Tribal Managed Care.

Develops mechanisms and supports to ensure the Vision, Mission and Values are reinforced.

Develops partnerships and coalitions to address social/environmental determinants of health and improve the overall health and well-being of the Cherokee.

Ensure the development and implementation of all operational policies and procedures 

Ensures CIHA CEO is informed of key areas of operations, risks, and incidents. 

Maintains an effective organizational structure and communication flow that ensures that leadership staff  have the necessary information and capacity required to manage in a highly complex, at-risk, regulatory environment.

Provides leadership, supervision, and professional growth opportunities to direct reports and shares with other members of the leadership team

In collaboration with the Quality Management Director, ensures the development, implementation and oversight of a robust quality management program that ensures member safety and access to high quality healthcare services. 

In collaboration with the Quality Management Director, ensures the development, implementation, and oversight of a corporate compliance program for the Tribal Managed Care including program integrity activities aimed at detecting and eliminating fraud, waste, and abuse.  Provides support to the Compliance Officer and ensures required reporting lines are established. 

Ensure agency achieves readiness to obtain national accreditation for health plan management functions and develops and maintains infrastructure and systems to monitor ongoing compliance with standards.  Once the Tribal Managed Care is in operations, will work collaboratively with Leadership Team to maintain maximum EQRO compliance.

Monitors effective organizational performance and compliance as it relates to all Medicaid, local, State, and Federal laws, and regulations

Ensure the organization implements robust health information technology clinical and administrative platforms that supports all areas of health plan operations.  This platform must link all aspects of the Tribal MCO operations including but not limited to:  Population Health, State and federal reporting, NC DHHS Contract requirements, and financial/claims processing.  

Ensures compliance with terms and conditions of DHHS Tribal Managed Care Contract.

Examines processes and implements policies and procedures to continually improve upon the operation of the Tribal Managed Care. 

Monitor the progress of health care reform and Medicaid transformation in relationship to the operations of the Tribal Managed Care.  

Prepare reports as required and requested 

Fiscal and Business Management

Works collaboratively with the CFO in monitoring the financial requirements of the Tribal Managed Cares, including financial solvency requirements, all financial reporting to the State and Medical Loss Ratio (MLR) and managed care cost containment results.

In conjunction with Leadership, sets strategic direction for short and long-term financial growth for the Medicaid scope of business in conjunction with other payers.

Ensures the establishment of an annual Tribal Managed Care budget and monitors organization performance against budget targets.  Ensures implementation of corrective actions when needed. 

Investigates, develops and implements new managed care programs as appropriate

Participates in rate negotiations as needed and ensures contracted rates for managed care/health plan activities are sufficient to sustain staffing and infrastructure needed to meet all contractual and applicable local, State, Federal and accreditation standards. 

Provider a leadership role in developing strategy to maximize performance and Establish innovative provider relationships that promote strong provider performance, pay 4 performance and value based contracting.  

Contribute to the oversight of the use of any vendors in the provision of managed care tools or operations and determine when tools and expertise should be developed internally

Medical and Clinical

In conjunction with the Chief Clinical Director (CCD), ensures the development of a medical, clinical management program responsible for utilization management and review, care management, care coordination and member health and safety.

Assist in the implementation and adherence to care management tools related to operations of the Tribal Managed Care

Develop the mechanisms within the Tribal Managed Care to mitigate risk by understanding population specifc drivers of utilization and cost under the risk-based Medicaid contract and identifying actionable leverage points for influencing the drivers.

Through the Director of Network Management establish and monitors a provider network that ensures members have access to covered services within all applicable network access and adequacy standard.

In collaboration with the CCD, ensure that network providers are educated and adhere to approved clinical guidelines and deliver evidenced based

medicine, services and supports.

Through the CCD and Health Information Technology leadership, ensure the development and implementation of a healthcare analytic program that can risk stratify,  levels of impact ability, identify members in need of additional  intervention, inclusive of Opioid dependence and overdose risks and other Tribal Health Initiatives.

Ensure the development and oversight of a Member Services Department responsible for all areas of enrollee services, including support to access healthcare and support services. 

Supervision/Guidance Received

The Tribal Managed Care Director reports to the CEO.   The employee exercises a great deal of independence; may consult with the CEO, Clinical Director, and other Directors in resolving issues and maintaining consistency and continuity across agency operations. The work is considered authoritative and is reviewed within an administrative context.

Personal Contacts

The personal contacts are with DHHS Officials, subordinates, co-workers, higher ranking managers, leadership of outside entities, patients, and members of the community. The purpose of the contacts are to exchange information, resolve differences between subordinates. The incumbent represents the CIHA in defending, identifying and negotiating with contractors, private agencies, other government agencies in meetings, conferences, and/or hearings.  Customer Services is an important aspect of the Tribal Managed Care.  


A Bachelor's degree in Healthcare or Business Administration or comparable degree and managed care experience, Master's degree preferred
Minimum five (5) years’ proven experience in healthcare industry, preferably management experience in: health insurance, managed care, or IPA/PHO management at the mid to senior level is required.  Knowledge of Medicaid managed care is preferred.   Experience working in the insurance industry that contracts for benefits under a variety of models such as risks, fee for service, shared savings across payer categories such as governmental, commercial and direct to employer.  

Other Requirements:

Excellent verbal, written and interpersonal skills a must.   

Excellent analytical and organizational skills with strong attention to details

Proven ability to solve problems and make sound decisions

Ability to work collaboratively with cross functional agency units  and departments

Ability to work independently and within a team environment

Ability to function effectively within an ever-changing environment to meet deadlines and re-prioritize as necessary

Proficiency in MS Office and Managed Care tools and platforms

OTHER: Incumbent is responsible for insuring that active EEO and Affirmative Action Programs emphasizing Indian Performance, the EEO Act of 1972 and the OCAO/IHS Area Policy Statement in EEO are in place. Must also insure subordinates have free and confidential access to information about EEO and affirmative action. Submits reports on EEO matters in a timely and efficient manner.

Customer Service
Consistently demonstrates superior customer service skills to patients/customers by displaying Language of Caring behaviors and skills. Ensure excellent customer service is provided to all patients/customers by seeking out opportunities to be of service. 

Embraces role models and implements all elements of our customer service program. Partners and coordinates with other departments to ensure total patient/customer satisfaction and efficient operations in a safe, friendly, comfortable environment, by well-trained, motivated employees. Recommends and implements change to improve overall patient/customer satisfaction.