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Director - Outpatient Case Management in Orange at Prospect Medical Systems

Date Posted: 1/17/2019

Job Snapshot

Job Description

Director - Outpatient Case Management

We are hospitals and affiliated medical groups, working closely together for the benefit of every person who comes to us for care. We build comprehensive networks of quality healthcare services that are designed to offer our patients highly coordinated, personalized care and help them live healthier lives. Through collaboration, we strive to provide all of our patients and medical group members with the quality, affordable healthcare they need and deserve.

Director Outpatient Case Management (CM) provides national executive leadership and advocacy for the consistent implementation of evidence-based, best practice case management interventions aimed at achieving efficiency, effectiveness, as well as, member/family and provider satisfaction. Optimizes case management resources and processes – outpatient and inpatient to ensure the seamless interaction and shared goals among the member’s care team. Evaluates all outpatient and inpatient handoffs to ensure the selection of the best supportive resources delivered to the member in a coordinated fashion at the right time in the right setting. Directs the development of meaningful case management reports that are generated routinely and utilized to assess the allocation of case management resources for specific populations (health plan contract/product) and rebalance as needed. Collaborates with the medical directors to establish, track, and report medical utilization benchmarks; develop and test innovative programs/initiatives as needed for performance improvement; and provide expertise in the selection and use of outside vendors and other leveraged support resources. Provides leadership and expertise in securing regulatory and health plan compliance with case management standards of practice. Collaborates with the leadership teams across the organization to facilitate the achievement of common business goals and share case management subject matter expertise and program successes.    

Job Responsibilities/Duties

  • Manages the overall budget for case management for the California market

  • Oversees CM position control and hiring of new staff

  • Directs and optimizes the development and implementation of evidence-based, best practice CM processes and interventions

  • Establishes and evaluates CM productivity metrics; reviews CM ratios (by health plan/product) routinely and directs caseload rebalancing as needed

  •  Contributes to the clinical, quality, financial, and member/beneficiary and provider satisfaction outcomes for the California market.

  • Acts as a resource to other departments across the organization regarding case management, and special considerations of frailty and high chronic condition burden.

  • Directs the development and maintenance of a repository of CM requirements from all CA contracted health plans and products or lines of business

  • Provides oversight of case management compliance with all external and internal CM requirements and ensures the quality of CM provided to members/beneficiaries

  • Collaborates with the Internal Audit Team to ensure CM case audit thresholds are met and compliance issues are identified for prompt resolution

  • Responsible for meeting and exceeding Compliance Requirements, conducting Root Cause Analysis, and Corrective Action Plans.


Minimum Education: Bachelor's Degree.

Minimum Experience: Five to ten (5-10)years of hands on outpatient case management experience. Two to three (2-3) years’ experience in a director or above role within a medical management organization.

Req. Certification/Licensure: Registered Nurse or BSN required, with extensive case management and senior leadership experience.

Employee Value Proposition

Prospect Medical Holdings, Inc., is guided by a diverse and highly experienced leadership core. This group maintains the vision that has made Prospect a needed difference-maker in the lives of so many patients today, and many executives contribute to our continued efforts. As a member of our highly effective team of professionals you will receive:

  • Company 401K
  • Medical, dental, vision insurance
  • Paid time-off
  • Life insurance

How to Apply

To apply for this role, or search our other openings, please visit and click on a location to begin your journey to a new career with us!

We are an Equal Opportunity/ Affirmative Action Employer and do not discriminate against applicants due to veteran status, disability, race, gender, gender identity, sexual orientation or other protected characteristics. If you need special accommodation for the application process, please contact Human Resources.

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