This position is responsible to strategize, lead and drive key operational aspects within the Clinical Services Department, to include staff orientation & training, cross functional project coordination, Clinical Services Performance Management and Process Improvement, Utilization Review, Intake and Coaching. Provide leadership, direction, and support for services to ensure best practices are employed to achieve quality outcomes, reduce/contain costs, and support a high-performance team culture. Additionally, shape policies and interpret the standards required to ensure a high level of member, medical director, and external stakeholder satisfaction.
Provide leadership and mentor to assigned operations area leaders, while team building, ensuring operational preparedness, regulatory compliance, Clinical Service analytics and performance management.
Support Clinical Services Operation’s service areas, clinical systems, analytics, and operations.
Provide back-up coverage in absence of managers/supervisors.
Oversee day-to-day operational support of the utilization management, intake, and health coaching service areas. Consult with the Vice President, Clinical Services and make recommendations for clinical services business functions related to direct report areas.
Maintain knowledge and understanding of managed care policies, regulatory requirements, and key payer, and provider contract provisions as related to clinical systems, utilization management and health coaching.
Collaborate with clinical services leaders, medical directors and other departments to facilitate effective population-based programming.
Monitor overall utilization management effectiveness, consult with medical directors and other key stakeholders to review, and facilitate effective utilization management programming and interventions to ensure medical expense remains within established benchmarks.
Maintain knowledge of relevant laws (ex: Data Privacy Act), regulations and ensure team updates department and/or organization policies as appropriate.
Oversee the development of systems, metrics, and policies/procedures to meet regulatory requirements (CMS & DHS) and NCQA standards to achieve the goals and business objectives of the Clinical Services area. Ensure application of policies and procedures that support assigned functional areas.
Create a performance driven programmatic and staff environment, where each area has objective measures for both program improvement and staff success.
Develop and maintain assigned budgetary responsibilities relevant to primary areas of oversight.
Lead and/or participate in work groups and committees as assigned.
Support orientation and ongoing training to facilitate service delivery and professional growth. Prepare staffing matrixes, monitors, and manages staff productivity, and revises staffing plan as appropriate.
Support coordination of projects and process improvement activities as requested by the Vice President, Clinical Services.
Participate in the selection and orientation of assigned staff to ensure appropriate screening, hiring, and effective selection of staff members.
Represent us as an active member of work groups, sub-committees, interactions with regulators, and special projects. Some travel may be required.
Participate as a key member of the Clinical Services leadership team and work collaboratively with the Vice President, Clinical Services and Medical Directors to develop the annual department plan.
Collaborate with Vice President, Clinical Services to strategically advance, implement and evaluate our utilization management programs.
Ensure utilization management and health coaching quality metrics demonstrate continued improvement in the area of Stars/HEDIS measures and business objectives.
Collaborate with others to engage staff and corrects course as appropriate related to our Staff Engagement survey results. Promote positive employee engagement and appropriate communication with staff.
Other projects and duties as assigned.
Bachelor’s degree in nursing or related field. An unrestricted and current Minnesota licensure in the field of Nursing.
Master’s degree in business, Nursing, Healthcare Administration or Hospital Administration preferred.
Five years clinical practice experience in a variety of health settings (hospital based, LTC, etc.).
Seven years progressively responsible management/supervisory experience that has included analyzing and recommending solutions for development of clinical systems and operations, utilization management and health coaching in a health insurance environment or other affordability/medical management related experience.
Comprehensive knowledge of Medicare and Medicaid rules/regulations related to utilization management services.
Knowledge of payer utilization management and health coaching models and principles.
Project Management; prior background in payer specific clinical systems and data analysis; strong knowledge and acumen regarding business process and clinical operational systems such as Clinical Informatics.
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