Sr Director of Clinical Operations
The Sr. Director of Clinical Operations is responsible for the oversight, development and management of the Health Plan’s Clinical Operations Team including Utilization Management (UM) and Care Management (CM) staff in accordance with HSCSN’s CASSIP contract. This includes cross functional team collaboration and development of policies, procedures, workflows, and special projects. As the leader of clinical (CM and UM) operations, this position reports directly to the HSCSN Chief Medical Officer with a matrixed reporting relationship to the HSCSN Chief Psychiatric Medical Officer and the Chief Operating Officer. The Sr. Director of Clinical Operations develops and implements high-touch, family-centered care management and utilization management programs to serve the unique care needs of HSCSN enrollees. The position works closely with the Chief Medical Officer to ensure effective clinical, quality, and medical management operational processes and policies that align with targeted quality outcomes and goals for enrollees. Oversees the provision of a range of services and benefits in accordance with the CASSIP contract from multiple network providers. Establishes processes that coordinate the provision of covered health care services with other community services available in the District of Columbia including educational, social, and disability services. Promotes linkage between utilization management, care coordination and quality improvement activities. Acts as a role model for clinical staff, promoting education, development and adoption of the CQI process. Promotes teamwork, and works independently, while maintaining appropriate communication with CMO and Senior Leadership.
Master’s Degree Business, Health Care Administration or Public Health (Required)
Minimum Work Experience
5 years prior experience working in utilization management and/or case management with sound clinical background (Required)
3 years prior experience working within a health plan (Preferred)
Knowledge and experience in care management, utilization management, and population health strongly preferred.
Deep understanding of standard operations of a health plan.
Familiarity with Medicaid regulations for health plans and EPSDT.
Strong project management, change management, process improvement and operational management skills.
Excellent leadership and team-building skills.
Excellent communication skills.
Demonstrates cultural sensitivity and diversity awareness in all interactions.
Required Licenses and Certifications
Certified Case Manager or equivalent (Preferred)
Leadership and Oversight for Clinical Operations
Leads the Clinical Operations Team in working with other functional areas to achieve successful implementation of HSCSN clinical strategy and goals.
Develops and implements effective and efficient standards, protocols, processes, decision support systems, reporting and benchmarks that promote quality, cost-effective health care services for HSCSN enrollees and ongoing improvement of clinical operations.
Monitors and evaluates key care management and utilization management processes, procedures and practices to optimize efficiency, ensure compliance with regulatory, contractual, and NCQA standards, and achieve the organization’s mission and goals.
Continually refines operational processes and champions review of team processes, workflows and activities.
Works with IT staff to define care management and UM system requirements, which meet regulatory, operational, reporting and analytic needs.
Compliance of Clinical Operations with contract, regulations, and standards of practice
Works closely with Compliance Department to ensure that clinical operations (UM & UM) are in compliance with CASSIP contract requirements and deliverables, code of federal regulations, and District of Columbia municipal code.
Routinely monitors and evaluates key care management and utilization management processes, procedures and practices to optimize efficiency and and ensure compliance with CASSIP, CFR, DCMR and NCQA standards.
Implementation of Quality Improvement initiatives within Clinical Operations
Works closely with with Quality & Accreditation Department to ensure that CM and UM meet NCQA standards for accreditation.
In partnership with Quality Department, CMO, CPMO & CQO, defines quality and performance metrics for CM and UM.
Develops initiatives to improve quality metrics and leads the clinical implementation and operational changes.
Responsible for ensuring care management implementation of performance improvement projects and disease management strategies.
Collaborates with Quality Department on implementation of population health and social determinants of health initiatives.
Development, revision and implementation of Policies and Procedures for Clinical Operations
Has working knowledge of HSCSN Policies and procedures.
Works with Medical Affairs, Compliance, and other functional areas to develop and revise HSCSN policies.
Responsible for the revision of UM and CM policies and ensuring that they are in compliance with the CASSIP Contract, Code of Federal Regulations, and other applicable standards.
Personnel Management for staff in the UM & CM Departments
Mentors, guides, trains, and develops skills of clinical team managers in a consistent and effective manner.
Ensures that monthly auditing of clinical staff is performed and appropriate actions and/or coaching occur.
Responsible for oversight of clinical training activities and outcomes.
Promoting career development and opportunities for HSCSN Clinical Operations staff.
Responsible for development and implementation of programs to promote recruitment and retention of knowledgeable, skilled, and talented HSCSN clinical staff.
Responsible for cultivating relationships with external organizations for recruitment of interns and future HSCSN clinical employees (CM & UM).
Responsible for oversight and monitoring of clinical delegation.
Develops and maintains a collaborative and positive working relationship on behalf of HSCSN Clinical Operations with the District of Columbia Department of Healthcare Finance (DHCF).
Ensures that deliverables to DHCF from CM and UM are submitted timely and in compliance with specifications.
Facilitates integration of care coordination with CASSIP program partners – Child & Family Services Administration (CFSA), Department of Youth Rehabilitation Services (DYRS), Department of Behavioral Health (DBH), Office of the State Superintendent of Education (OSSE), Department of Disability Services (DDS), and Katie Beckett.