Job Summary:

The Medical Management Director - CSMV is responsible for leading CareSource Military & Veterans' integrated medical management model, including Utilization Management (UM), Case Management (CM), Behavioral Health (BH), Population Health (PH), Clinical Quality Management (CQM), and Pharmacy Management. This role ensures day-to-day operational compliance with TRICARE requirements and reporting obligations, drives high-quality and cost-effective care, reduces unwarranted variation and waste, and supports reduction in Total Cost of Care (TCOC) for the TRICARE Prime Competitive Plans Demonstration.

Essential Functions

• Provide strategic and operational leadership for the Medical Management function across UM, CM, BH, PH, CQM, and Pharmacy.
• Oversee utilization management activities, including prospective, concurrent, and retrospective review of beneficiary care.
• Oversee prior authorization processes, benefit and service determinations, and inpatient and emergency department concurrent review and census management.
• Oversee clinical appeals processes, including medical necessity and factual appeal determinations and coordination with qualified clinical reviewers.
• Ensure effective case management services, including transition in and out of the plan, condition management, and post-discharge transitions of care.
• Lead population health strategies, including targeted outreach for high-risk and chronic condition populations.
• Oversee behavioral health integration and coordination with medical and case management operations.
• Ensure compliance, performance monitoring, and reporting for clinical quality and pharmacy management programs.
• Ensure timely and accurate completion of all Government-required medical management deliverables and reports.
• Perform any other job related duties as requested.

Education and Experience

• Bachelor's degree in Healthcare Administration, Public Health, Nursing, or a related field required
• Master's degree in Healthcare Administration, Public Health, Nursing, or a related field preferred
• Equivalent years of relevant work experience may be accepted in lieu of required education
• Eight (8) years progressive experience in medical management, utilization management, or managed care clinical operations. required
• Five (5) years in a leadership role. preferred
• TRICARE or Veteran Affairs experience preferred

Competencies, Knowledge and Skills

• Strong written, verbal, and executive-level communication skills.
• Ability to manage competing priorities and deadlines in a fast-paced environment.
• High level of professional judgment, accountability, and integrity.
• Demonstrated ability to collaborate and influence cross-functionally

Licensure and Certification

• Active, unrestricted Registered Nurse (RN) license preferred
• Certified Case Manager (CCM) preferred
• Certified Professional in Utilization Review (CPUR) preferred
• other relevant clinical certification preferred

Working Conditions

• General office environment; may be required to sit or stand for extended periods of time
• Remote capabilities
• Up to 15% (occasional) travel to attend meetings, trainings, and conferences may be required