Director of Self-Funded Clinical Services
The Health Plan of West Virginia Inc Massillon, OH
- Expired: over a month ago. Applications are no longer accepted.
The Director of Self Funded Clinical Services provides leadership, management, oversight and assessment of all aspects of utilization management (UM) and member driven care coordination programs for self funded clients while ensuring appropriate delivery of essential services to address total health care needs of The Health Plan's self funded membership. The Director of Self Funded Clinical Services reports to the Chief Medical Officer (CMO) and works collaboratively with Benefit Services, Population Health (PHM) and the THP Medical Directors, as well as other leaders to plan, organize, coordinate, develop the vision, perform implementation and measure the outcome of all UM and care coordination programs for self funded clients to ensure adherence to purchased programs and plan documents.
- Registered Nurse with a minimum of five (5) years of clinical experience.
- Minimum of two (2) years of management experience.
- Minimum of five (5 ) years of managed care experience with expertise in self funded business desired.
- Active unencumbered licensure in Ohio or West Virginia upon hire, both within ninety (90) days of hire.
- Proficiency with Microsoft Office Programs (Word, Excel, Outlook, PowerPoint).
- Excellent communication skills. Proficiency with public speaking. Strong verbal, written, analytical and interpersonal skills.
- Motivation, initiative and ability to work independently as well as demonstrated ability to lead a team. Proven leadership ability.
- Experience in writing, interpreting and implementing policies and procedures.
- Ability to work in a fast paced environment and adapt to change. Flexibility, adaptability and ability to multi-task
- Experience in self funded sales presentations and Request For Information/Request for Proposal processes and preparations.
- Demonstrated experience with population health management and measuring, reporting outcomes in a clinical setting.
ESSENTIAL FUNCTIONS AND RESPONSIBILITIES:
- Oversees medical and behavioral UM operations inclusive of reference based pricing and external network relationships for all self funded clients.
- Oversees medical and behavioral care coordination programs for all self funded clients.
- Provides direct supervision to self funded line of business managers and supervisors.
- Develops and monitors UM and Care Coordination processes, policies and procedures for self funded units.
- Develops and enhances system of reporting and metrics to be utilized for productivity, adherence and outcome measurements to provide relevant information on overall effectiveness of UM and Care Coordination activities.
- Leads medical management and behavioral health UM and Care Coordination integration with Health Systems as related to Self Funded products and services.
- Collaborates with CMO, Benefit Service team members/Account Executives and PHM team to ensure cross-functional and interdepartmental alignment on self funded client projects and programs. Coordinates and reports on goal attainment for projects and programs.
- Implements and monitors clinical services care coordination and UM program software and platforms related to self funded line of business.
- Provides input into self funded clinical services medical/behavioral evidence based care coordination and UM program criteria sets inclusive of prior authorization list.
- Interacts with designated group representatives and Benefit Services staff at set intervals to facilitate and/or report on care coordination and UM program integration with individual.
The Health Plan of West Virginia Inc
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