The Chief Operations Officer (COO), a member of the Executive Leadership Team, reports directly to the Chief Executive Officer and supervises five direct reports. This role will oversee Clinical Operations and Service Development, Quality Management, Utilization Management, Access, Care Coordination, Support Facilitation and Cardinal Innovations Healthcare Solutions (“Cardinal Innovations”) Community Operations Centers (COC). The COO will ensure operational compliance with contract, federal, state rules and regulations, as well as with Cardinal Innovations operational policies and procedures.
The Chief Operations Officer is responsible for (though not limited to):
Clinical Advisory Committee (Clinical Guidelines) -
Provide advice to Chief Medical Officer in research activities related to best practices and clinical guidelines. Monitoring implementation of clinical guidelines as related to Utilization Management (UM) department activities and decisions. Provide clinical support for authorizations, including approval of exceptions and out-of-network authorizations. Ensure systems are in place for proper documentation.
Clinical Policies and Procedures -
Ensure clinical policies and procedures, as well as medical necessity criteria are implemented appropriately and monitored regularly.
Medical Necessity -
Ensure UM decisions are made in accordance with Medical Necessity criteria for each service.
Utilization Management Plan
- Clinical support to Clinical Operations Director, Clinical Directors and Access Director in determining appropriate course of treatment; participate in clinical case staffing; assist with strategies to provide solutions for difficult cases.
Clinical Design Plan
- Oversee development of the annual UM plan. The plan will include goals, target thresholds and reports required to monitor performance.
– Collaborate with Cardinal Innovations clinical employees to develop a Clinical Design Plan consistent with the goals and objectives of the company.
Management of Community Operation Center (COC) –
Oversight of all operations/functions of the COC, including management, budgetary and community involvement responsibilities. Support and advise COC leaders, regional COC executives, and Local Advisory Boards ensuring alignment of Cardinal Innovations’ overall goals and objectives. Ensure that the COC’s are in compliance with Division of Medical Assistance (DMA) and Department of Mental Health (DMH) contract guidelines, including other state and federal regulations. Ensure that providers are adequately providing quality service.
Risk Management Plan
- Participate in development of the Risk Management Plan as related to utilization and access, including the identification of thresholds for performance. Responsible for monitoring performance related to utilization and access and for implementation of corrective actions as required.
– Serve as Chair of the Utilization Review Committee. Develop utilization review plan and strategies to monitor performance thresholds, develop strategies to address outliers, and attain utilization goals. Ensure that Utilization Management processes and protocols are established and followed consistently. Ensure inter-staff reliability, through peer review and other strategies. Review utilization data against utilization targets.
Desired Skills & Experience
- Oversee appeals process and ensure compliance with Medicaid regulations. Monitor data on Medicaid appeals for trends, consistency of reviews, and identify training needs of staff.
The Chief Operations Officer must be process oriented with business operation acumen and demonstrated ability to empower others to perform at the highest level of their ability. As a Cardinal Innovations Executive Leadership Team member, the employee should be able to foster and encourage open dialogue, promoting frank discussion of tough issues and encourage others to express contrary views. The employee must stay abreast of important federal and state trends and activities that could potentially impact the business. Additionally, the Chief Operations Officer must fully grasp the position of business within the marketplace; demonstrate a thorough understanding of the Cardinal Innovations position, capabilities and new service opportunities.
An undergraduate degree is required, though a master’s degree is highly preferred. Candidate must have at least ten years of progressive experience in management, with at least seven years of executive level clinical experience. Managed Care experience is highly desired.
This is both an office based and community based position, which occurs primarily during normal working hours. Some evening, weekend work, and other extended work hours may be required to meet business needs.
Cardinal Innovations is North Carolina’s largest Managed Care Organization providing Medicaid managed care and state-funded behavioral health plans. Our mission is to enhance the health and well-being of individuals and their families by creating and managing quality healthcare solutions for those who depend on the public system for care. Our plans reflect the uniqueness of our local communities and are capable of making continual adjustments and improvements to meet the changing needs and priorities of our clients. Cardinal Innovations values the contribution of all stakeholders, and our businesses are based on the principles of respect, collaboration, and mutual accountability.
Cardinal Innovations is an Equal Opportunity Employer.
All Interested candidates must apply on line.