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The Director of Clinical Excellence – Workers’ Compensation role involves a blend of clinical leadership and expertise in workers’ compensation utilization review and case management. As a member of our client's Clinical Operations team, the Clinical Excellence Lead is responsible for fostering an environment that promotes quality, continuous improvement and adherence with best practices. They are also responsible for collaborating with clients and internal stakeholders to shape clinical strategies and solutions that drive quality, efficiencies, and compliance with business, accreditation, and jurisdictional requirements.
Under the direction and oversight of the SVP, Clinical Operations, the Director will lead the clinical strategy and day-to-day clinical training and quality operations for workers’ compensation vertical ensuring high-quality, cost-effective care coordination, appropriate utilization and timely return-to-work outcomes. They will provide strategic direction and clinical guidance, design and operationalize evidence-based strategies to achieve client/business objectives and foster a culture of clinical excellence, continuous improvement and measurable performance. In addition, the Director will facilitate and support the resolution of client issues and clinical operation challenges. Serving as the workers’ compensation clinical program expert, they will provide clinical guidance and direction, design, implement and maintain clinical programs that improve quality and clinical performance. They will partner with our workers’ compensation clients and various departments including Sales, Compliance, Clinical Operations, Account Management, Business Excellence, Quality and Training to provide differentiating and distinctive service(s) that support the achievement of business outcomes/targets and our client’s strategic goals/objectives.
The Director of Clinical Excellence – Workers’ Compensation will: Develop, execute and maintain the clinical strategy for workers’ compensation ensuring the strategy is aligned with goals (quality, outcomes, cost, performance, growth and client satisfaction). Translate strategic priorities into operational roadmaps, policies, workflows, staffing models and technology requirements engaging the appropriate business stakeholders when needed. Lead annual clinical planning (goals, budgets, FTEs, programs), manage workers’ compensation training and quality budget and participate in quarterly/annual business reviews with executives and clients. Identify, prioritize and lead clinical initiatives of various sizes and complexity aimed at improving quality and performance. Coordinate activities for all assigned projects/initiatives from readiness assessment and planning to completion of implementation, which may include facilitating clinical training/education and developing clinical training content. Conduct business discovery discussions with clients, internal stakeholders, and staff as appropriate to determine root cause for clinical escalation and most appropriate action(s) to resolve issue(s). Lead effort to design clinical job aids and reference guides to aid staff with improving quality, performance, promote adherence with accreditation standards and facilitate compliance with evidenced-based guidelines and jurisdictional requirements. Collaborate with client and internal stakeholders to resolve clinical operational issue(s)/challenge(s) in a timely manner. Develop clinical performance reports that allow for and enable process improvement and clinical trend analysis. Drive clinical quality: chart audits, clinical supervision, case rounds/conferencing and remediation plans as appropriate. Define, measure and evaluate clinical performance data to determine the impact and effectiveness of action plan. Partner with analytics/business excellence to build dashboards and use insights to design/refine strategy and target high-impact business interventions. Address clinical education and clinical review knowledge gaps. Develop relationships and establish clinical credibility with clients and internal stakeholders Facilitate communication between clinical team and client during biweekly training and quality alignment meetings which includes fielding questions, maintaining frequently asked questions (FAQ) log, and disseminating information via team huddles/email communications. Remain updated with applicable clinical criteria, standards of care, accreditation standards and jurisdictional requirements. Lead, mentor and develop high-performing quality audit and training team as well as drive engagement, succession planning, competency development ad ongoing training for direct reports and their teams. Support accreditation compliance and activities. Perform other duties as assigned.
Qualification requirements: To perform this job successfully, the qualified candidates will have: An active, unrestricted registered nurse licensure in the United States Bachelor’s degree in nursing is required Master's degree in nursing preferred Minimum 7 years of experience working in workers’ compensation with at least 5 years of experience in utilization management and 2 years of experience in case management At least 5 years in leadership role managing multi-site, national and/or global teams required At least 2 years of experience working with global teams Previous experience working within a matrix environment preferred Experience and knowledge of workers’ compensation regulations, utilization review process, evidenced based guidelines (ODG/ACOEM), case management, accreditation standards (URAC) and jurisdictional requirements Experience with clinical training and quality required Knowledge of and demonstrated proficiency with using SharePoint, Microsoft Excel (including pivot tables), Microsoft Word, Microsoft PowerPoint, Microsoft Visio, Microsoft Teams, Webinar. Computer literate with in-depth knowledge, experience working with databases, graphics, and spreadsheets to generate clinical performance reports required Certified Case Manager Certification is required within 3 years of being in the role Excellent communication (written and verbal) and stakeholder management skills with client-facing experience required Demonstrated success designing and executing clinical strategies that improve outcomes (quality and performance) Strong Strategic Thinking and Execution with a demonstrated ability to convert goals into scalable programs with measurable key performance indicators Ability to use analytics to target interventions, monitor impact and evaluate/interpret clinical data, summarize results, and make recommendations Ability to demonstrate accuracy and thoroughness, monitor their own work to ensure quality and apply feedback to improve clinical performance Ability to work independently and collaboratively with teams of individuals with diverse skills, experience and backgrounds Demonstrate an ability to shift priorities and juggle multiple work projects/initiatives Requires initiative, strong problem-solving ability, and self-motivation Demonstrates strong critical thinking skills with ability to make independent decisions. Ability to critically think and devise plans to address deficiencies and track corrective action(s) to closure Passion for lifelong learning and development with ability to effectively research, assess and utilize information (internal and external sources) to develop plan of action, make recommendations and/or decision Ability to work under minimal supervision but able to recognize when to seek out guidance/direction or escalate
Position Logistics The role is a full-time position reporting to SVP, Clinical Operations for Workers’ Compensation Programs. This position is a remote position. Must have a current and valid passport. Travel up to 30% travel (domestic and international). Travel to headquarters in Nashville, client site/location(s) and delivery center(s) in the Philippines and India. Must be willing to work outside of traditional US working hours.
Under the direction and oversight of the SVP, Clinical Operations, the Director will lead the clinical strategy and day-to-day clinical training and quality operations for workers’ compensation vertical ensuring high-quality, cost-effective care coordination, appropriate utilization and timely return-to-work outcomes. They will provide strategic direction and clinical guidance, design and operationalize evidence-based strategies to achieve client/business objectives and foster a culture of clinical excellence, continuous improvement and measurable performance. In addition, the Director will facilitate and support the resolution of client issues and clinical operation challenges. Serving as the workers’ compensation clinical program expert, they will provide clinical guidance and direction, design, implement and maintain clinical programs that improve quality and clinical performance. They will partner with our workers’ compensation clients and various departments including Sales, Compliance, Clinical Operations, Account Management, Business Excellence, Quality and Training to provide differentiating and distinctive service(s) that support the achievement of business outcomes/targets and our client’s strategic goals/objectives.
The Director of Clinical Excellence – Workers’ Compensation will: Develop, execute and maintain the clinical strategy for workers’ compensation ensuring the strategy is aligned with goals (quality, outcomes, cost, performance, growth and client satisfaction). Translate strategic priorities into operational roadmaps, policies, workflows, staffing models and technology requirements engaging the appropriate business stakeholders when needed. Lead annual clinical planning (goals, budgets, FTEs, programs), manage workers’ compensation training and quality budget and participate in quarterly/annual business reviews with executives and clients. Identify, prioritize and lead clinical initiatives of various sizes and complexity aimed at improving quality and performance. Coordinate activities for all assigned projects/initiatives from readiness assessment and planning to completion of implementation, which may include facilitating clinical training/education and developing clinical training content. Conduct business discovery discussions with clients, internal stakeholders, and staff as appropriate to determine root cause for clinical escalation and most appropriate action(s) to resolve issue(s). Lead effort to design clinical job aids and reference guides to aid staff with improving quality, performance, promote adherence with accreditation standards and facilitate compliance with evidenced-based guidelines and jurisdictional requirements. Collaborate with client and internal stakeholders to resolve clinical operational issue(s)/challenge(s) in a timely manner. Develop clinical performance reports that allow for and enable process improvement and clinical trend analysis. Drive clinical quality: chart audits, clinical supervision, case rounds/conferencing and remediation plans as appropriate. Define, measure and evaluate clinical performance data to determine the impact and effectiveness of action plan. Partner with analytics/business excellence to build dashboards and use insights to design/refine strategy and target high-impact business interventions. Address clinical education and clinical review knowledge gaps. Develop relationships and establish clinical credibility with clients and internal stakeholders Facilitate communication between clinical team and client during biweekly training and quality alignment meetings which includes fielding questions, maintaining frequently asked questions (FAQ) log, and disseminating information via team huddles/email communications. Remain updated with applicable clinical criteria, standards of care, accreditation standards and jurisdictional requirements. Lead, mentor and develop high-performing quality audit and training team as well as drive engagement, succession planning, competency development ad ongoing training for direct reports and their teams. Support accreditation compliance and activities. Perform other duties as assigned.
Qualification requirements: To perform this job successfully, the qualified candidates will have: An active, unrestricted registered nurse licensure in the United States Bachelor’s degree in nursing is required Master's degree in nursing preferred Minimum 7 years of experience working in workers’ compensation with at least 5 years of experience in utilization management and 2 years of experience in case management At least 5 years in leadership role managing multi-site, national and/or global teams required At least 2 years of experience working with global teams Previous experience working within a matrix environment preferred Experience and knowledge of workers’ compensation regulations, utilization review process, evidenced based guidelines (ODG/ACOEM), case management, accreditation standards (URAC) and jurisdictional requirements Experience with clinical training and quality required Knowledge of and demonstrated proficiency with using SharePoint, Microsoft Excel (including pivot tables), Microsoft Word, Microsoft PowerPoint, Microsoft Visio, Microsoft Teams, Webinar. Computer literate with in-depth knowledge, experience working with databases, graphics, and spreadsheets to generate clinical performance reports required Certified Case Manager Certification is required within 3 years of being in the role Excellent communication (written and verbal) and stakeholder management skills with client-facing experience required Demonstrated success designing and executing clinical strategies that improve outcomes (quality and performance) Strong Strategic Thinking and Execution with a demonstrated ability to convert goals into scalable programs with measurable key performance indicators Ability to use analytics to target interventions, monitor impact and evaluate/interpret clinical data, summarize results, and make recommendations Ability to demonstrate accuracy and thoroughness, monitor their own work to ensure quality and apply feedback to improve clinical performance Ability to work independently and collaboratively with teams of individuals with diverse skills, experience and backgrounds Demonstrate an ability to shift priorities and juggle multiple work projects/initiatives Requires initiative, strong problem-solving ability, and self-motivation Demonstrates strong critical thinking skills with ability to make independent decisions. Ability to critically think and devise plans to address deficiencies and track corrective action(s) to closure Passion for lifelong learning and development with ability to effectively research, assess and utilize information (internal and external sources) to develop plan of action, make recommendations and/or decision Ability to work under minimal supervision but able to recognize when to seek out guidance/direction or escalate
Position Logistics The role is a full-time position reporting to SVP, Clinical Operations for Workers’ Compensation Programs. This position is a remote position. Must have a current and valid passport. Travel up to 30% travel (domestic and international). Travel to headquarters in Nashville, client site/location(s) and delivery center(s) in the Philippines and India. Must be willing to work outside of traditional US working hours.