Director of Health Services for National Medicaid Clinical Operations RN

Profile

Description

The Director of Health Services for National Medicaid Clinical Operations utilizes clinical skills to support the coordination, documentation and communication of medical services and/or benefit administration determinations. The Director, Health Services requires an in-depth understanding of how organization capabilities interrelate across the function or segment.

Responsibilities

As Humana's Medicaid membership continues to grow, the National Medicaid Clinical Operations team is expanding our shared services organization to enhance the clinical delivery process. The Director of Health Services for National Medicaid Clinical Operations uses clinical knowledge, communication skills, and independent critical thinking skills towards interpreting criteria, policies, and procedures to provide the best and most appropriate treatment, care or services for members. Coordinates and communicates with providers, members, or other parties to facilitate optimal care and treatment. Decisions are typically related to the implementation of new/updated programs or large-scale projects for the function and supporting technical/operational procedures and processes, and implements strategic plans, drives goals and objectives, and improves performance. Provides input into functions strategy. The Director will be responsible for implementing and delivering National Medicaid Clinical Services to new markets , including leadership for centralized functions and staff.

Detailed Responsibilities include:

Directs and leads Medicaid shared services operational process and teams responsible for supporting new Medicaid Market Clinical Operations delivery including:

Developing Outpatient Prior Authorization and Clinical Claims Review processes and leading the Centralized Outpatient Utilization Management operations team;

Providing Clinical subject matter expertise and oversight for Medicaid's Preauthorization List development, implementation, administration, and routine updates;

Implementing operational support tools, including Workforce Management planning and consultation with market Clinical leaders, to identify operational best practices and process opportunities;

Developing Clinical Quality Audit processes for UM and CM teams; directing audit team that delivers audit process and consultation with new market leaders for identifying improvement opportunities;

Implementing 24/7 After Hours Clinical coverage process and oversight of team providing after hours member support services;

Creating operational process consistency and alignment across Medicaid for Clinical Letters/Correspondence, Clinical Member and Provider-facing Materials, and Medicaid Operations clinical content delivery.

Key Qualifications

Registered Nurse required ;

Bachelor's Degree required in Clinical or Behavioral Health field;

Master's Degree strongly preferred in Clinical, Social Work, or Business-related field;

10 years of clinical or behavioral health experience required ;

7 years of Managed Care Operations Leadership experience required ;

5 years of Utilization Management Operational program development and leadership experience required ;

Medicaid and/or D-SNP experience required ;

5 years developing collaborative partnerships with enterprise cross-functional teams required ;

2 years of experience in Clinical Compliance, Quality Audit, or NCQA background strongly preferred ;

5 years of leading large scale implementations and/or centralized services teams strongly preferred ;

Integrated Medical & Behavioral Health Operating Model knowledge and experience desirable ;

Demonstrated experience and recommendations from peers as a customer-focused, team player, with collaborative approach to leading is required .

Scheduled Weekly Hours

40

Company info

Humana Inc.
Website : http://www.humana.com