Responsible for clinical leadership and oversight of health management processes and teams to ensure quality outcomes and effective use of resources. Works in conjunction and collaboration with operational leadership and Senior Physician/Medical Director to understand clinical trends, engage with clients and prospects to align on clinical success criteria and implement operational controls to achieve criteria/targets.
 
Responsible for supporting leadership and operational teams with process and performance improvement initiatives from concept to implementation. Develop and manage clinical programs that maintain the utilization of best practices and emphasize timely, appropriate, cost-effective care. Scope of responsibilities include health management services such as Utilization Management (UM), Care Management, and other integrated care functions such as Discharge Planning and Care Management program to promote a coordinated, interdisciplinary process in the continuum of care.
 
Key Responsibilities:
Brings subject matter knowledge, clinical leadership and management experience to clinical operation teams relying on experience and judgment to plan and accomplish goals/achieve desired outcomes.
Oversees clinical quality and training programs across all health management clients which includes program design, development and implementation.
Directs the clinical management leads, quality, training, regulatory compliance, and accreditation staff.
Oversees team responsible for monitoring ongoing compliance with state and federal requirements for the UM department, supports business with completing business impact assessment(s) and implements actions to correct issues, improve and maintain compliance.
Responsible for setting up and maintaining Clinical Operations that comply with applicable regulation and accreditation requirements for existing and new clients.
Develops relationship with the client and serves as a point of contact for escalated clinical issues.
Consults with and/or refers clinical issues to the Senior Physician/Medical Director/Client’s Clinical Leadership as needed and appropriate.
Provides support to attain and maintain accreditation from URAC, NCQA or other applicable accrediting bodies.
Collaborates with quality and operations to review trends, identify root cause, and implement quality improvement initiatives to address trends and opportunities.
Develops resource tools and conducts training to educate the clinical and administrative staff in the many aspects of clinical, delegated functions and operational policies and procedures at least annually to ensure staff competence.
Evaluates effectiveness of clinical training programs and facilitates corrective action as appropriate.
Serves as point of contact for designing and developing new client delivery capabilities and clinical programs/workflows.
Supports the organizational objective to have qualified clinicians that are accountable to the organization for decisions affecting health care consumers.
Manages clinical resources, including but not limited to overall staffing, performance management, succession planning, resource optimization, and time allocation.
Collaborates with Client’s clinical leadership team to improve efficiency and effectiveness of services, and to identify solutions to identified issues or escalations.
Maintains business and industry knowledge to guide customers with strategic delivery decisions.
Participates in strategic planning for existing and expanding business includes setting growth objectives, contributing to strategy, building internal and client relationships, and supporting sales pursuits including RFP responses/presentations, client meetings, and site visits.
Actively participates during sales presentations and provides subject matter expertise for clinical-related issues.
Job Requirements:
This role will require travel approximately 20% of the time to include international travel