Director, Government Programs Clinical Operations
Core
Directing change in processes and integrating projects for Government Programs Clinical Operations (Medicare Advantage, Dual Eligibles, Medicaid) across Medical Management organizations.
Role type
Senior IC Director of Clinical Operations
Builds
Clinical review processes, cost of care initiatives, clinical management tools, and performance improvement plans.
Domain
Healthcare / Insurance / Government Programs
Required skills
Managed care operations, care management, quality of care, public/government health sponsored programs, Medicaid claims payments rules, State and Federal regulations, accreditation standards (NCQA, EQRO), managed care principles, quality improvement, business requirements, reporting, project management, budgeting, resource allocation, cost-benefit analysis.
Preferred skills
Master's in Nursing or Health Sciences, Case Management/Health Care Administration/Project Management certification, pediatric special needs/chronically ill/disabled/low income/frail population experience, MDCP/Texas State Special Needs Waivers experience, Texas Medicaid experience, new program implementations, English/Spanish bilingualism.
Technologies
Microsoft Suite
Responsibilities
Direct change in processes and integration of projects for Government Programs Clinical Operations products; optimize clinical review process across Operations, Marketing/Sales, and Medical departments; ensure compliance with accreditation standards and government regulations; direct and develop cost of care initiatives and clinical management tools; oversee triage and reporting of high dollar claims; direct quality analysis, performance analysis, and customer service standards; oversee performance guarantees and implement performance improvement plans; manage staff including goal setting, performance management, and talent development.
Seniority
Senior, hands-on IC
