Arcadia Healthcare Solutions

  • Director, Value-Based Care Services (RN)

  • Overview

    Are you passionate about supporting primary care transformation, helping health care and community based providers to be able to improve systems that support the delivery of high quality care and cost containment for their practices/organizations? Do you have expertise in primary care operations and person-centered coordinated care processes and are able to help health care teams understand how to integrate medical, behavioral health and care management services? Plus, expertise in developing training for staff that work to risk stratify panels, identify high risk patients, and provide care management and coordination?


    If you understand that healthcare’s shift to value-based payment models requires organizations to focus on improving care and engagement of high risk/high need individuals, then we want to talk to you! We want to hear your ideas on employing a population management approach, implementing team-based and integrated care models, quality improvement, and addressing the social determinants of health are all methodologies and more. 


    • Responsible for the leadership of the day to day operations within the Value Based Services Team.
    • Function on leadership level for the Value based services department, specifically leading the Utilization Review (UR), Care Coordination (Population Health) and Quality Improvement (QI) teams.
    • Understand and maintain awareness of the changing healthcare landscape including the evidence base, reimbursement reform and delivery system transformation.
    • This position is responsible for directing a variety of clinical functions of utilization management, case management, complex case management and quality improvement.
    • Establish or implement cost-containment goals, objectives, metrics, and Return on Investment (ROI) targets for Medical Care Management Programs.
    • Ensure staff meet/exceed goals and standards.
    • Ensure compliance with health plan and client service agreements. Implement Policies/Procedures and Training Programs to support the clinical department.
    • Serves as clinical administrative contact for current and prospective client organizations, attending UM Committee and BOD meetings as necessary.
    • Responsible for and manages the implementation of the Managed Care LoB Utilization Management (UM) plan and the Complex Case Management programs according to client contract terms
    • Per client contracts requirements, oversee and ensure successful and timely completion of the annual UM and QI audits and surveys.
    • Responsible for direct management and compliance of client-specific managed care contracts, including contractual audit and reporting processes.
    • Oversees and coordinates orientation, training, continuing education and ongoing performance monitoring of clinical and non-clinical clinical care staff.
    • Coordinates utilization management activities with each client organization and their Medical Director.
    • Oversee process for the preparation and presentation of monthly utilization management data/reports to the QI/UM Committee and/or other committees as needed.
    • Supervise and coach the nursing staff in their role as facilitator of monthly QI/UM committee meetings.
    • Communicate accurately with the Medical Director/Physician Advisor, ordering providers, provider organizations, members and their representatives, and all customers.
    • Oversee and ensures ongoing compliance with company policies and procedures, applicable Federal and state laws and regulations, and the URAC standards.
    • Promotes the nursing staff’s continued professional growth and education reflecting the knowledge and understanding of current nursing care practice as outlined in the Illinois Nurse Practice Act.
    • Implements necessary procedures to maintain compliance with federal and state regulatory requirements, delegation requirements and URAC/NCQA standards.


    • Registered Nurse (RN) with current, valid license in state of operations.
    • 5 years people management experience.
    • 5 years clinical nursing experience.
    • 2 years HMO medical management experience.
    • 1 year clinical audit preparation experience.
    • Certification in Case Management, Health Care Administration or Project Management preferred.
    • Experience and skills in influencing, leading and directing individuals in multiple functional areas.
    • Ability to manage a business unit/multiple lines of business, while also leading and working on one or more projects.
    • Knowledge of various accreditation standards, i.e., NCQA, URAC, etc.
    • Knowledge of managed care principles and delivery systems.
    • Familiar with claims payment rules and their impact on care management processes.
    • Knowledge of healthcare/insurance industry, current and future trends i.e. bed days per K and Average LOS analysis.
    • Knowledge of service delivery processes, workflow, systems, reporting needs, training and quality.
    • Organizational skills and ability to function cooperatively to achieve organizational goals and objectives.
    • Communication, leadership, team building, and quantitative analysis skills.
    • PC proficiency including familiarity with various software programs i.e., Word, Excel, PowerPoint, Access, etc.
    • Strong organizational, writing and presentation skills necessary.
    • Ability to prioritize and react based on rapidly changing business needs.


    • Bachelor’s degree in Nursing from an accredited institution
    • Master’s Degree in related field desired


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