PacificSource Health Plans · 1 month ago
Director, Enterprise Care and Disease Management
Bend, OR
Full-time
Hybrid
Mid, Senior Level
7+ years expPacificSource Health Plans is dedicated to helping members access quality, affordable care. The Director of Enterprise Care and Disease Management leads the design and execution of an integrated care management model, overseeing various programs to improve health outcomes and enhance member experiences.
CommunitiesCustomer ServiceNon Profit
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
Qualification
Required
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
Bachelor's degree in Nursing required
Current, unrestricted Registered Nurse (RN) license required
Certified Case Manager (CCM) certification required within 2 years of hire
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)
Preferred
Additional experience managing complex work processes, including D-SNP, Medicaid, Medicare, Quality Programs (CMS Stars, OHA, NCQA) preferred
Company
PacificSource Health Plans
Founded in 1933, PacificSource is a not-for-profit health insurer for people and organizations throughout the Northwest.
1001-5000 employees
Funding
Current Stage
Late StageLeadership Team
John Espinola MD MBA
President and CEO
Erick Doolen
Chief Operating Officer
Recent News
2025-11-29
2025-10-22
Company data provided by crunchbase