EmblemHealth
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UM Director Clinical Operations- REMOTE
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EmblemHealth Overview
Work across the enterprise to help advance the modernization of utilization management, implement strategic process improvements, and provide analytical evaluation of appropriateness and efficiency of medical necessity. This role serves as an integral strategic partner for ongoing monitoring and improvements of the use of health care services and procedures. Evaluate and help build inpatient care management and concurrent review. The role aims to reduce denials, improve member care and provider relations. Demonstrate the ability to handle multiple priorities and to articulate and represent EmblemHealth’s strategy to executive leaders across the enterprise and external partners. Work with Senior Leadership to define and monitor Utilization Metrics while collaborating with Clinical Administration partners on deployment strategies. Develop course correction strategies to address Utilization Metrics that fail to meet performance standards and work closely with Corporate Compliance to ensure all Federal, State Regulations, NCQA Requirements, and Corporate Policies related to prospective, concurrent, and retrospective review processes are embedded in the service level agreements with vendors. Provide services per the NYCE contract. Principal Accountabilities
Drive UM operational performance for each core process and align with EmblemHealth strategic objectives. With leadership, establish best practice for ensuring operational control with an effective process for monitoring critical performance metrics to assure compliance with Medicare Advantage program and NCQA standards, as well as state and federal regulatory requirements. Work internally and in tandem with Provider Collaboratives and outsourced vendors to identify and implement integrated care coordination and population health management strategies that maximize skills and resources to improve members’ health care experience, reduce medical expense and improve quality outcomes. Assure department workflows and policies/desktop procedures are aligned and accurate at all times. Communicate and collaborate with internal stakeholders including Clinical Administration, G&A, Compliance and Product as needed to share data/trends, promote change, achieve optimal performance, and support overall EmblemHealth strategic and tactical objectives. Advise leadership on improvement opportunities regarding medical expense programs and clinical activities that impact service delivery, including utilization review, risk management, and quality assurance of medical programs to ensure judicious use of resources and high-quality care. Provide clinical and workflow management oversight for design, development, testing and implementation of software applications used to support Clinical Operations. Drive to raise the bar in outcomes by partnering and developing the skills and medical management capabilities of physician organizations and partnerships. Support the Quality and Pharmacy departments to sustain HEDIS STARS. Prepare for and deliver information related to State, Federal, and Accreditation Audits and Monitoring. Collaborate with Directors of Operations, Compliance and Analytics to proactively prepare for ongoing events. Foster a collaborative environment and continuously coach and mentor direct reports and vendor staff to achieve higher levels of Medical Management competencies. Ensure a high performing work culture is embedded within the departments. Identify and address gaps for developing competencies. Continually assess activities and processes to ensure efficiency, effectiveness, and added value. Qualifications
Bachelor's Degree RN with Master’s degree preferred 10+ years of experience in a Managed Care Environment with significant experience in Utilization Management (concurrent review, discharge planning, pre-cert) Equivalent combination of education and experience preferred At least 7 years of clinical and disease management experience Proven experience in creating, implementing and managing care and disease management programs Ability to interpret and apply guidelines to effectively control medical costs (e.g. M&R, InterQual) Ability to navigate successfully through a matrixed environment using influence to drive behavior Ability to build a team and foster high morale and commitment Strategic and tactical perspective on improving operational performance Excellent communication skills (written and verbal) Highly organized Working knowledge of CareAdvance and Facets Additional Information
Requisition ID: 1000002686 Hiring Range: $135,000-$253,800 Seniority level
Director Employment type
Full-time Job function
Research, Analyst, and Information Technology Industries Insurance
#J-18808-Ljbffr
UM Director Clinical Operations- REMOTE
role at
EmblemHealth Overview
Work across the enterprise to help advance the modernization of utilization management, implement strategic process improvements, and provide analytical evaluation of appropriateness and efficiency of medical necessity. This role serves as an integral strategic partner for ongoing monitoring and improvements of the use of health care services and procedures. Evaluate and help build inpatient care management and concurrent review. The role aims to reduce denials, improve member care and provider relations. Demonstrate the ability to handle multiple priorities and to articulate and represent EmblemHealth’s strategy to executive leaders across the enterprise and external partners. Work with Senior Leadership to define and monitor Utilization Metrics while collaborating with Clinical Administration partners on deployment strategies. Develop course correction strategies to address Utilization Metrics that fail to meet performance standards and work closely with Corporate Compliance to ensure all Federal, State Regulations, NCQA Requirements, and Corporate Policies related to prospective, concurrent, and retrospective review processes are embedded in the service level agreements with vendors. Provide services per the NYCE contract. Principal Accountabilities
Drive UM operational performance for each core process and align with EmblemHealth strategic objectives. With leadership, establish best practice for ensuring operational control with an effective process for monitoring critical performance metrics to assure compliance with Medicare Advantage program and NCQA standards, as well as state and federal regulatory requirements. Work internally and in tandem with Provider Collaboratives and outsourced vendors to identify and implement integrated care coordination and population health management strategies that maximize skills and resources to improve members’ health care experience, reduce medical expense and improve quality outcomes. Assure department workflows and policies/desktop procedures are aligned and accurate at all times. Communicate and collaborate with internal stakeholders including Clinical Administration, G&A, Compliance and Product as needed to share data/trends, promote change, achieve optimal performance, and support overall EmblemHealth strategic and tactical objectives. Advise leadership on improvement opportunities regarding medical expense programs and clinical activities that impact service delivery, including utilization review, risk management, and quality assurance of medical programs to ensure judicious use of resources and high-quality care. Provide clinical and workflow management oversight for design, development, testing and implementation of software applications used to support Clinical Operations. Drive to raise the bar in outcomes by partnering and developing the skills and medical management capabilities of physician organizations and partnerships. Support the Quality and Pharmacy departments to sustain HEDIS STARS. Prepare for and deliver information related to State, Federal, and Accreditation Audits and Monitoring. Collaborate with Directors of Operations, Compliance and Analytics to proactively prepare for ongoing events. Foster a collaborative environment and continuously coach and mentor direct reports and vendor staff to achieve higher levels of Medical Management competencies. Ensure a high performing work culture is embedded within the departments. Identify and address gaps for developing competencies. Continually assess activities and processes to ensure efficiency, effectiveness, and added value. Qualifications
Bachelor's Degree RN with Master’s degree preferred 10+ years of experience in a Managed Care Environment with significant experience in Utilization Management (concurrent review, discharge planning, pre-cert) Equivalent combination of education and experience preferred At least 7 years of clinical and disease management experience Proven experience in creating, implementing and managing care and disease management programs Ability to interpret and apply guidelines to effectively control medical costs (e.g. M&R, InterQual) Ability to navigate successfully through a matrixed environment using influence to drive behavior Ability to build a team and foster high morale and commitment Strategic and tactical perspective on improving operational performance Excellent communication skills (written and verbal) Highly organized Working knowledge of CareAdvance and Facets Additional Information
Requisition ID: 1000002686 Hiring Range: $135,000-$253,800 Seniority level
Director Employment type
Full-time Job function
Research, Analyst, and Information Technology Industries Insurance
#J-18808-Ljbffr