Director, Medical Management
Job Description
About the Company:
TECQ Partners operates as a value-based care organization supporting Medicare Advantage populations through direct contractual relationships with national and large enterprise health plans. The organization focuses on full-risk care models that align clinical outcomes, provider performance, and financial accountability. Its operating approach is designed to support coordinated care delivery while creating alignment between member needs and provider incentives.
Through its administrative and clinical platform, TECQ Partners enables provider groups to dedicate greater time and attention to patients with complex medical needs. Providers work within a single, integrated framework rather than managing multiple payer relationships, and participate in structured quality and performance programs tied to outcomes and cost management.
TECQ Partners provides an end-to-end set of operational and clinical support services in compliance with Centers for Medicare & Medicaid Services (CMS) regulations and National Committee for Quality Assurance (NCQA) standards. These services include utilization management and case management activities, claims adjudication and payment operations, provider credentialing, regulatory and compliance support, financial and revenue cycle services, network oversight, population health management, quality and HEDIS performance improvement, and value-based care program execution.
Learn more at tecqpartners.com.
About the Position:
The Director of Medical Management provides operational oversight and performance leadership for Intake, Prior Authorization, Utilization Review, and related medical management correspondence, ensuring compliance with all regulatory, contractual, and accreditation requirements. The role also oversees Care and Case Management functions and is responsible for the strategic planning, scalability, and ongoing growth of the Medical Management department to support the current and future needs of TECQ Partners.
In this capacity, the Director of Medical Management serves as the primary liaison to contracted vendors and health plans for medical management related activities, including delegation oversight and audit coordination, particularly for plans that delegate credentialing and other medical management functions to TECQ Partners.
The Director of Medical Management works collaboratively across the organization and demonstrates the ability to foster strong communication and teamwork among physicians, medical management staff, corporate departments, external vendors, and senior leadership to support effective, compliant, and high-quality medical management operations.
This position, along with team members within assigned units and across the organization, fosters an engaging and professional environment committed to respect, inclusivity, continuous improvement, and teamwork.
Key Responsibilities:
- Quality Programs & Performance Improvement
- Utilization & Appeals Oversight
- Delegation Oversight & Health Plan Relations
- Policies, Procedures & Regulatory and Accreditation Compliance
- Operational & Workforce Management
- Leadership, Budgeting & Strategic Planning
- Professional Judgment & Development
Required Experience:
- 5+ years in a leadership position in care management in a health plan or medical group setting
- 5+ years of experience supervising clinical staff
- 2+ years of Medicare Advantage experience
- Experience working in a health plan or an integrated health model
- Current experience with CMS regulations and NCQA standards survey protocols
- Experience with process development and program implementation
- Comfortable working with partnered clinical health plans to support regulatory compliance and quality improvement programs
Required Qualifications:
- Active and unrestricted Texas RN licensure; if not currently licensed in TX, must have a current RN license and obtain TX RN within six months of hire date
- Bachelor’s degree required; master’s preferred
- Current knowledge of Texas State and CMS regulations; knowledge of NCQA standards
Erica Eikelboom, Principal & Executive Search Consultant
Morgan Consulting Resources, Inc.
erica@morganconsulting.com
ADDITIONAL POSITION DESCRIPTION
Leadership, Budgeting & Strategic Planning
- Accountable, in collaboration with executive leadership, for the annual development and ongoing management of budgets for Utilization Management (UM) and Care Management functions
- Establish organizational priorities for Medical Management teams and define strategic direction, scope of effort, and execution plans aligned with organizational objectives
- Forecast future operational needs related to growth, new services, and health plan expansion, and develop long-term plans to scale department capabilities accordingly
- Lead the development of the annual Medical Management Program Description, Work Plan, and Annual Program Evaluation
Operational & Workforce Management
- Recruit, hire, train, manage, evaluate, and set performance goals for Medical Management staff
- Oversee staffing models and ratios for UM and Care Coordination personnel to drive operational efficiency, regulatory compliance, and budget alignment
- Assign duties and responsibilities and evaluate workforce effectiveness in support of UM and Care Management program outcomes
- Manage departmental operations to optimize workflows, communication processes, and systems supporting effective patient care delivery
Policies, Procedures & Regulatory Compliance
- Plan, develop, implement, and maintain Medical Management policies and procedures for current and future UM and Care Coordination workflows in accordance with organizational performance goals, budgets, and timelines
- Establish and maintain compliance with all applicable Federal and State regulations, NCQA standards, and contractual obligations
- Responsible for regulatory requirements, policy updates, and mandatory training programs that are effectively disseminated, understood, and implemented by staff, vendors, and delegates
- Monitor compliance through routine oversight activities and participation in internal and external audits
Delegation Oversight & Health Plan Relations
- Serve as the Subject Matter Expert for delegation oversight, including pre-delegation assessments, ongoing monitoring, and annual audits of delegated administrative and clinical services
- Act as the primary liaison with health plans and delegated vendors for Medical Management functions, including audit coordination and performance oversight
- Oversee delegated entities performing utilization management, quality, and care management functions to secure adherence to contractual requirements and service level agreements
- Review regulatory guidance and payer requirements, communicate expectations to internal teams and delegates, and drive appropriate implementation
Utilization, Quality & Appeals Oversight
- Monitor Medical Management performance metrics, including authorization turnaround times, utilization review reporting, quality assurance activities, and disease management outcomes
- Assist in researching, responding to, and resolving issues related to initial determinations, appeals, and regulatory inquiries
- Trend and analyze quality, utilization, and cost data and support the development of internal and external performance reports
- Coordinate quarterly reporting of Medical Management initiatives to applicable committees and health plans
Quality Programs & Performance Improvement
- Support oversight of HEDIS®, Health Outcomes Survey (HOS), and CAHPS® performance analysis in collaboration with Quality and Compliance teams
- Partner with Compliance to develop, implement, and monitor corrective action plans as required
- Drive continuous improvement initiatives to enhance compliance, quality outcomes, and operational effectiveness
Professional Judgment & Development
- Make informed decisions and resolve complex operational or compliance issues using data-driven analysis and sound judgment
- Maintain current knowledge of healthcare industry trends related to utilization management, regulatory compliance, clinical performance reporting, and population health improvement
- Maintain professional development to remain current with evolving standards, regulations, and best practices in Medical Management
Additional Experience Required
- Ability to make decisions or solve problems by using logic, data to identify key facts, explore alternatives, and propose quality solutions
- Outstanding customer service skills as well as the ability to deal with people in a manner which shows tact and professionalism
- The ability to properly handle sensitive and confidential information (including HIPAA and PHI) in accordance with federal and state laws and company policies
Additional Qualifications Required
- Knowledge of standards of the National Committee for Quality Assurance (NCQA)
- Requires the ability to work in a demanding environment, to work a flexible schedule and to effectively resolve conflicts as they arise
- Excellent verbal and written communication skills
- Proficient with Microsoft OfficeWord and Excel
- Ability to focus for extended periods