Director of Clinical Operations

Job Ref: TE0071
Category: Professional
Department: CLINICAL SERVICES ADMIN
Location: 50 Water Street, 7th Floor, New York, NY 10004
Job Type: Regular
Employment Type: Full-Time
Work Arrangement: Hybrid
Salary Range: $181,000.00 - $191,426.00

Position Overview:
Under the supervision of the Chief Medical Officer, the Director of Clinical Operations will serve as a critical leader and collaborator across teams to optimize Utilization Management (UM), Care Management (CM, including Behavioral Health CM), Disease Management (DM), and Quality Management operations through supporting new system integration, resolving identified system issues, and enhancing day-to-day operations. This position will provide key support, oversight, and implementation support for all UM/CM/DM/QM operational workflows, regulatory requirements and program enhancements, and reporting requirements that require system changes to our core operating system, data warehouse, and clinical communications. The Director of Clinical Operations will also have dotted line reporting to the Senior Director of Business Intelligence and work performance accountability to the Deputy Chief Medical Officer, Vice President of Clinical Services, and Vice President of Behavioral Health for key initiatives that impact their departments’ workflows and processes.

Scope of Role & Responsibilities:
New Systems Implementation and Operations:
• Lead UM/CM/DM/QM new system implementation and operations.
• Maintain full knowledge of current clinical operations and impact analysis of planned changes for implementation.
• Lead systems and operations design to automate when possible and deliver all necessary reports and dashboards timely.
o Ensure all current workflows (clinical and non-clinical workflows) are accounted for in new system design.
o Work with all members of clinical teams conducting Utilization and Care Management (ICM, PIC, BH, CSS, Pharmacy, MLTC, UM, and Quality Management) to ensure processes are aligned and individual nuances areincorporated.
o Identify and implement enhanced workflows where applicable given new system capabilities.
o Report on system implementation status to medical management department leadership.
o Ensure comprehensive testing and tracking of results to facilitate regular updates to key stakeholders.
• Oversee system set up for clinical benefits and programs (automation, work queues, letters, reporting, training, regulatory and parity compliance, third party vendors).
• Act as the key clinical stakeholder for system updates and set-up, overseeing temporary staff, and ensuring CM/UM/DM/QM priorities are communicated and updated as needed.
• Develop training documents for both clinical and non-clinical staff to support successful implementation.
• Oversee implementation and maintenance of new benefits, clinical programs, and authorizations (includes design, testing and working with key stakeholders – Claims, CORE, Compliance, and Product) and obtain clinical department approval for all planned work.
• Collaborate with UM/CM/DM/QM SMEs across departments to define and document priorities for system enhancements and ensure accurate completion.
• Resolve all UM/CM/DM/QM identified system configuration issues.
• Ensure comprehensive testing and QC across all departments when implementing system updates.

UM/CM/DM Clinical Operations:
• Project manage Medical Management system alignment to support the delivery of high-quality care management, effective UM and NYS and CMS regulatory requirements.
• Collaborate with multiple departments (IT, Operations, Analytics, Claims, Core, and Quality Management), leveraging all available data sources across lines of business to optimize the UM program and implement model contract-compliant, high quality care management.
• Identify, escalate, and address any issues that may impact regulatory compliance (this includes system failure, operational issues, and audit findings).
• Drive implementation of annual/ad-hoc benefit reviews including benefit guide update, system updates, configuration, notification, and training).
• Drive regulatory-required reporting modifications.
• Identify root cause of complaints or inquiries and implement solutions to prevent issues from reoccurring.
• Develop productivity reports based on system enhancements to ensure staffing matrix is reflective of new and enhanced workflows and review with Medical Management department leadership for collective decision-making on recommended enhancements.
 

Required Education, Training & Professional Experience:
• Bachelor’s Degree required in a healthcare-related field, Master’s Degree preferred; and
• 10+ years of health care clinical administration; and
• 5+ years of progressively responsible UM and CM experience in a managed care plan; or
• A satisfactory equivalent combination of education, training, and experience
• Excellent process development/management skills to ensure tools, supportive technologies and operational flows are optimally utilized.
• Clinical background; well-versed in informatics, analytics, and decision-making skills
• Experience with NYS and CMS regulations and compliance.

Licensure and/or Certification Required:
• Valid, unrestricted New York State Registered Nurse (R.N.) license preferred

Professional Competencies:
• Integrity and Trust
• Customer Focus
• Excellent Microsoft Office Suite skills
• Excellent interpersonal, communications, problem-solving, innovative thinking and negotiating skills.
• Ability to lead and manage significant change.
• Ability to work cross-functionally and collaborate across the MetroPlusHealth leadership team

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