The Health Services Director is responsible for clinical operations and medical management activities across the continuum of care (assessing, planning, implementing, coordinating, monitoring and evaluating). This includes case management, coordination of care, and medical management consulting. The Health Services Director may also be responsible for directing health education, coaching and treatment decision support for members. Provides oversight and leadership to a field-based team of nurse clinicians responsible for the case management activities for Long Term Care members living in the community setting and in nursing homes.
Executes the delivery of all Clinical Programs (Utilization Management, Case Management/Service Coordination and Disease Management) for the Health Plan
Develops and implements clinical program structure and resource plans that are consistent with National Clinical Model based on populations serviced by Plan Ensures local clinical processes, policies and procedures meet regulatory/NCQA/CMS standards and are consistent with the national clinical model
Leads, Coaches, develops, clinical leadership staff, fosters innovation to improve member outcomes
Identifies and drives local Healthcare Affordability Initiatives along with medical director(s) and clinical team
Ensures monitoring and oversight of clinical programs/staff to meet defined goals/targets, contract requirements
Works collaboratively with providers, internal and external business partners, service contractors, and health plan management to oversee the management of a health services department with the objectives of improving the quality of care delivered to members in a range of products, i.e., Medicaid, CHIP, SSI/ABD, long term care, and dually eligible categories, improving cost efficiencies, and developing an environment of operational excellence
Interfaces with UHG enterprise to ensure clinical operations are compliant with State and Federal regulations
Collaborates with internal and external entities to improve accessibility standards and quality practice standards to reduce medical costs across the service delivery systems (inpatient, emergency departments, urgent care services and practitioner office settings)
Utilizes timely and meaningful financial and utilization reports to assist providers in efforts to alter their care delivery patterns and improve member outcomes
Develops, translates and executes strategies or functional/operational objectives for Health Plan including medical management, financial accountability, customer and Provider satisfaction, quality improvement
Develops and implements staff retention and engagement program
Serves as the Health Plan Health Services SME and liaison with the state
Ensures clinical staff training, onboarding, immersion and competency assessment processes meet contract requirements and clinical model standards
Required Education & Work Experience:
Bachelors in Nursing/ Registered Nurse licensure required
5 or more years of experience in development and execution of clinical programs in public sector managed care environment
Clinical experience with Medicaid/Medicare populations
5 or more years of experience leading a team of 15+ associates in a managed care environment
Masters in Nursing, Business, Healthcare Administration preferred
Medicaid Managed Care Experience in Long Term Care Programs
Field based case management program implementation and monitoring
NCQA/URAC Accreditation Experience
Required Knowledge, Skills, and Abilities:
Demonstrated track record of clinical program compliance, functional collaboration, and meeting program goals
Demonstrated track record of leadership development
Intermediate computer skills in: MS Office Suite- Powerpoint, Excel, Word, Project
UnitedHealthcare Community & State is part of the family of companies that make UnitedHealth Group one of the leaders across most major segments of the US health care system.
If you're ready to help make health care work better for more people, you can make a historic impact on the future of health care at UnitedHealthcare Community & State.
We contract with states and other government agencies to provide care for over two million individuals. Working with physicians and other care providers, we ensure that our members obtain the care they need with a coordinated approach.
This enables us to break down barriers, which makes health care easier for our customers to manage. That takes a lot of time. It takes a lot of good ideas. Most of all - it takes an entire team of talent. Individuals with the tenacity and the dedication to make things work better for millions of people all over our country.
You can be a part of this team. You can put your skills and talents to work in an effort that is seriously shaping the way health care services are delivered.
UnitedHealth Group invests in employees through a comprehensive compensation and benefits program, 401(k) savings, retirement and stock plans, education reimbursement, and much more.
Diversity creates a healthier atmosphere: equal opportunity employer M/F/D/V
UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment. In addition, employees in certain positions are subject to random drug testing.