The Director - RN Clinical is responsible for the day to day medical management operations, inclusive, but not limited to maintaining production metrics, delivering on current service level agreements, fulfilling contractual requirements and supporting future state initiatives while meeting strategic, operational and budgetary targets. Additionally, the continued development of solid clinical quality programs and robust clinical training are requirements, as well as the execution of appropriate utilization management policies and procedures. In collaboration with key business partners, the Director - RN Clinical shall identify operational opportunities and areas for process development, improvement and administration applicable to clinical product offerings.
- Oversee operational performance relating to Operational metrics, Quality measures, Contractual requirements, Execution of MBM policies and procedures and Clinical appropriateness.
- Oversee the administration of clinical programs, including application of medical policy, utilization management processes and practices while remaining compliant with contractual and regulatory requirements.
- Development and implement solid clinical quality programs that support current state needs and future product services.
- Align with key business partners to support the ongoing development of future MBM product offerings.
- Accountable for the design and execution of the UM work plan and associated tasks.
- Continual identification of operational opportunities to gain efficiencies, improve processes and workflow and develop best practices.
- Oversee clinical training to maintain highly effective clinical programs, support contractual obligations and meet regulatory standards.
- All other duties as assigned.
- Bachelor’s degree in relevant discipline.
- 10-15 years relevant experience or Master’s degree with 8-12 years relevant experience.
- Registered Nurse.
- Solid PC navigation skill set.
- Working knowledge of Microsoft Office.
- Excellent verbal, written communication and presentation skills.
- Solid understanding of the health insurance industry.
- Ability to navigate and support both public and private insurance/plan requirements.
- Managed care exposure.
- Understanding or ability to implement utilization management principles.
- Proven leader in a clinical ops environment.
Job Id: REQ20010219