Director – Integrated Clinical Care

Purpose of the job

Provide leadership and oversight for clinical operations services, including utilization management, medical claims review, and clinical training and auditing. These services aim to manage medical costs and improve population health. Develop and implement management programs to meet the demographic and epidemiological needs of our members across Commercial, Individual, and government lines of business (FEP and Medicare). Ensure strategic implementation of compliance and regulatory requirements, including accreditation and federal and state mandates.

REQUIRED QUALIFICATIONS

• 7 years of clinical experience
• 5 years of management experience
• 5 years of managed care, utilization management review, health services health outcomes, or disease management experience, specifically in developing and implementing clinical programs
• 5 years of experience in developing short and long range strategic plans, forecasting, and budgeting

• Associate’s degree in healthcare, healthcare administration, business administration or related field

• N/A

• N/A

PREFERRED QUALIFICATIONS

• 10 years of management experience
• 10 years of clinical experience in a primary care field
• 10 years of managed care, health services, health outcomes, or disease management experience, specifically in developing and implementing clinical programs
• 5 years of experience in developing short and long range strategic plans, forecasting, and budgeting

• Bachelor’s degree in healthcare, healthcare administration, business administration or related field

• Active, current, and unrestricted license to practice in the State of Arizona (a state in the United States) as a health professional, including RN, LCSW, LPC, LISAC LMFT, Psy.D. or Ph.D.

• N/A

ESSENTIAL job functions AND RESPONSIBILITIES

• Provide leadership to medical management operations of utilization management, concurrent review, clinical training & auditing, and medical claims review and ensure they meet the demographic and epidemiological needs of our members.
• Ensure compliance with all regulatory agencies over Medicare and Commercial business related to the application of Evidence Based Medicine Medical Policy processing, including the CMS Interoperability and Patient Access Final Rule. Ensure all State, Federal, BCBS Association and Accreditation processing requirements are satisfied.
• Identify data-informed, strategic directions and improvements for health and population management systems and propose options, including budget forecasts, system roadmaps and functionality.
• Promote plan-wide understanding, communication, and coordination of clinical operation services including cross-functional collaboration across clinical, information technology, compliance, and operational teams to enhance workflows, data exchange, and improve member and provider experience.
• Manage use of corporate funds including budgeting, financial management, and reporting. Identify opportunities to achieve administrative efficiencies while maintaining service.
• Collaborate with Data Science and Analytics to analyze utilization and identify opportunities to offer additional health management services to various customer segments, as well as trend analysis and development of services for program advancement and improved cost of care.
• Assist with the development and integration of new products as they relate to areas of responsibility including management of requests for proposals and requests for information.
• Provide leadership, administrative and management support, strategic planning and overall direction of medical management, utilizing the principles of continuous process improvement to impact efficiency, effectiveness and outcomes.
• Provide leadership and management in the support of workflows to support business growth and evolving strategies. Oversee and coordinate from a business owner perspective, the business requirements, end-to-end testing and user acceptance testing for processes involving areas of responsibility.
• Ensure appropriate productivity standards are monitored and in line with industry standards; analyze staffing models to support productivity and encourage efficiencies in process.  Forecast staffing-based trends, system changes and healthcare programs.
• Support development of Medical Policy, technology implementation and publication of the Medical Coverage Guidelines (Medical and Administrative Policy Manual), along with associated clinical criteria, pertinent to medical policy issues.  Oversee interrater reliability throughout the clinicians.

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Overall

• Demonstrate quality management standards in daily problem solving within respective areas of responsibility leading by example and managing by fact.
• Ensure new programs are integrated with all functional areas, including delegated entities, and responsive to competitive market demands.
• Function as an SME for the clinical/medical management programs and presents the programs to clients and other external agencies both in-person and written.
• Oversee day-to-day departmental administration by coaching and motivating managerial staff and departmental personnel to make maximum use of experience and skills.
• Monitor quality performance measures, develop and maintain effective workflows, and seek to maximize system efficiencies.
• Manage use of corporate funds including budgeting, financial management, and reporting. Identify opportunities to achieve administrative efficiencies while maintaining service.
• Provide leadership for accreditation activities for areas of responsibility
• Participate in strategic planning activities and contribute to departmental and cross-functional teams to achieve BCBSAZ goals. Support BCBSAZ’s Core Value of maintaining a heritage of service, by volunteering with, serving on, and/or supporting multiple Boards of Directors within the community.
• This position has in office requirements of two days per week and requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as needed to meet business requirements.
• Maintain effective working relationships to ensure teamwork in achieving corporate goals.
• Perform all other duties as assigned.