Director, Enterprise Care and Disease Management

Job Summary:

The Director of Enterprise Care and Disease Management leads the design and execution of an integrated, enterprise-wide care management model across all lines of business—Commercial, Medicare, Medicaid, D-SNP, and specialty programs. Responsibilities include oversight of Transitions of Care (TOC), Rising/Emerging Risk Management, Moderate/High-Risk Case Management, D-SNP Care Coordination, and Disease Management (DM). This role ensures delivery of high-quality, cost-effective care management that improves health outcomes, enhances member experience, reduces avoidable utilization, and meets regulatory and quality standards (CMS Stars, NCQA, OHA QIMs). Success requires strong clinical expertise, deep knowledge of chronic disease pathways, proven experience implementing DM interventions (e.g., diabetes and hypertension control), proficiency in risk stratification, and the ability to manage vendors and deploy innovative care models.

Essential Responsibilities:

• Oversee risk-tiered programs including Transitions of Care (TOC), rising/emerging risk, moderate/high-risk, D-SNP, and Disease Management across all lines of business.
• Design and implement disease management programs to improve chronic condition outcomes (e.g., HbA1c, BP, COPD, CHF) and achieve Stars, HEDIS, and QIM performance metrics.
• Establish consistent care pathways, assessment tools, workflows, and outcome monitoring for case and disease management programs.
• Integrate predictive analytics and risk stratification to identify high-need members and guide targeted interventions.
• Track outcomes, utilization, readmissions, and cost indicators through dashboards and reporting tools.
• Direct daily operations, maintain regulatory compliance (CMS, NCQA, state), and oversee HRAs, assessments, and individualized care plans
• Align DM, CM, UM, BH, pharmacy, and quality programs to deliver a cohesive population health strategy.
• Lead vendor selection, integration, audits, and performance oversight to ensure SLAs, quality standards, and clinical outcomes are met.
• Champion adoption of tools for predictive analytics, remote monitoring, and member engagement.
• Utilize Lean methodologies, visual boards, and daily huddles to monitor KPIs and drive process enhancements
• Oversee hiring, coaching, performance reviews, and staff development. Promote accountability and clinical excellence.
• Develop budgets, participate in enterprise initiatives, RFP development, and quality strategy.
• Collaborate with providers and internal teams to optimize care coordination. Embed evidence-based practices and motivational interviewing in care management programs.
• Drive integration of physical, behavioral, and oral health programs within the care management model.
• Actively participate in strategic committees, enterprise projects, and RFP development to align care management with organizational goals.
• Work with providers, community organizations, and stakeholders to strengthen care coordination and address social determinants of health.

Supporting Responsibilities:

• Partners with providers, community organizations, and internal departments to coordinate care and optimize member engagement.
• Participate in and support project teams led by other departments and provide necessary input to support the goals of colleagues.
• Meet department and company performance and attendance expectations.
• Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
• Perform other duties as assigned.

SUCCESS PROFILE

Work Experience: Minimum of 7 years of experience in healthcare management or utilization management to include 3 years of leadership experience required. Experience in case management, disease management, utilization management and program development using evidence-based medicine required. Additional experience managing complex work processes, including D-SNP, Medicaid, Medicare, Quality Programs (CMS Stars, OHA, NCQA) preferred.

Education, Certificates, Licenses: Bachelor’s degree in Nursing required. Current, unrestricted Registered Nurse (RN) license required. Certified Case Manager (CCM) certification required within 2 years of hire.

Knowledge: Requires expertise in Medicare, Medicaid, and Commercial regulatory requirements (CMS, NCQA, state standards). Strong understanding of care management, utilization and case management, disease management, and population health. Knowledge of D-SNP Model of Care and integration of physical, behavioral, and oral health programs. Exceptional leadership, team building, and stakeholder management skills. Advanced analytical, strategic thinking, and problem-solving abilities. Proficiency with technology, predictive analytics, and data-driven tools. Familiarity with Lean/Six Sigma and quality programs (CMS Stars, NCQA, OHA).

Competencies

Authenticity

Building Organizational Talent

Coaching and Developing Others

Compelling Communication

Customer Focus

Empowerment/Delegation

Emotional Intelligence

Leading Change

Managing Conflict

Operational Decision Making

Passion for Results

Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 30% of the time.