Senior Director - Clinical Programs

September 15

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Martin's Point Health Care

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TRICARE Prime • Medicare Advantage • Medicare Part D • Health Care • Primary Care

501 - 1000

Description

• Proposes and plans new programs and services to meet population health needs, customer expectations, and activities to manage medical costs and focus on health outcomes. • Develops objectives across the department to ensure compliance with professional and regulatory standards, federal contracts, and accreditation standards. • Develops and leads high performing care management coordination activities to reduce cost per capita for all member populations while ensuring members receive appropriate and needed services. • Leads care management and disease management activities for Martin’s Point to improve clinical and medical trend outcomes. • Oversees all reporting to monitor the progress and outcomes of all care management and disease management activities carried out by the department including reporting to regulatory and accrediting agencies. • Manages relationships and coordination with external vendors and delegated entities. • Responsible for Delegation Oversight of Clinical vendors • Develops and manages Key Performance Indicators (KPIs) for care management and disease management. • Partners with cross functional teams to successfully enhance existing clinical program’s structure to address the needs of members, support the work of care teams, and align with our company objectives. • Proposes, designs, and oversees implementation of care management redesign and new products and services to meet population health needs, customer expectations, and activities to manage medical costs and focus on health outcomes. • Ensures all program design and redesigns are in compliance with professional and regulatory standards, federal contracts, and accreditation standards. • Collaborates across health plan clinical programs as well as other key health plan departments and the delivery system to ensure alignment of clinical and operational initiatives and activities. • Collaborates with the Director Health Plan Quality to support initiatives such as HEDIS, Member Safety, QIPs, QII’s, CMS Stars and accreditation. • Collaborates with clinical teams across Health Management synthesizing clinical outcome drivers and quality/operational requirements into an aligned program, strategy to deliver high-impact clinical outcomes, client value and business results.

Requirements

• Bachelor’s degree in a clinical field of study (RN, Pharmacy, etc.); Master’s degree in nursing or related field preferred • 10 years of experience in health care including experience in care management/ disease management, utilization management and prior authorization. • Experience developing and managing health plan program strategy, design, redesign, clinical platform conversions, implementation, and evaluation. • Experience using data and data analysis to design programs, manage care coordination services, and manage success of programs. • Strong project management experience required. • Experience in Medicare Advantage and TRICARE preferred.