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Director, Clinical Operations
Director, Clinical OperationsCentral Mass Health LLC • Worcester, MA, US
Director, Clinical Operations

Director, Clinical Operations

Central Mass Health LLC • Worcester, MA, US
[job_card.30_days_ago]
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  • [job_card.full_time]
[job_card.job_description]

Job Description

Job Description

Description :

Mass Advantage is a Medicare Advantage health plan, located in the heart of Worcester County, headquartered in Worcester MA. Mass Advantage is owned and designed by UMass Memorial Health providers with their patients’ needs in mind.

We are looking for a Director of Clinical Operations responsible for the oversight of clinical functions, including utilization management, care coordination, and integrated care processes, to ensure the delivery of high-quality, cost-effective care. Reporting to the Chief Medical Officer, this role will work collaboratively with the Chief Executive Officer, VP of Operations, Chief Compliance Officer, Chief Financial Officer, other senior leadership, and other health plan employees to develop and implement clinical strategies that align with organizational goals. The Director will play a key role in establishing policies and procedures, ensuring compliance with CMS and accreditation standards, and driving performance improvement initiatives. Experience in start-up environment with desire to build the organization’s sustainable and scalable clinical operations is key to success.

Utilization Management and Clinical Oversight

  • Perform reviews of operations and decision of delegated entity on services and determine the medical appropriateness of inpatient and outpatient care, following evaluation of medical guidelines and benefit determination.
  • Utilize clinical skills to telephonically provide and facilitate conversations around utilization review, continued stay reviews and utilization management of all cases based on clinical experience and recognized guidelines in conjunction with the delegated entity, as applicable.
  • Ensure evidence-based referral management, inpatient concurrent review, and care management to promote efficiency, effectiveness, and compliance with regulatory standards.
  • Provide industry-standard utilization and cost data measured against program-wide regional and external benchmarks / goals for all areas of service managed by the department.
  • Complete UM delegation responsibilities.

Care Coordination and Integrated Care

  • Manage and oversee the Care Management team, ensuring alignment with care management programs and organizational goals.
  • Collaborate with Social Work care managers, medical directors, and other plan and provider staff to coordinate care across the continuum, addressing both medical and behavioral health needs.
  • Advocate for patient needs, negotiate for services, and develop patient-centered care plans in collaboration with patients, caregivers, and healthcare providers.
  • Assess patient needs, including medical, behavioral health, and social determinants, and identify knowledge gaps to prioritize care.

    • Policy Development and Compliance

  • Assist senior leaders with program design and practices and write policies and procedures that meet CMS and accreditation standards.
  • Ensure compliance with all state and federal regulations and guidelines in day-to-day activities.
  • Lead audit activities, including CMS Program audits for Organizational Determinations, Appeals and Grievances, accreditation efforts (as applicable), and other regulatory audits.
  • Report quality of care issues identified during the utilization review process according to policy and procedure.

    • Performance Improvement and Reporting

  • Promote performance improvement; plans for and oversee systematic measurement, monitoring, and evaluation of care and services; designing and implementing improvement activities based on findings.
  • Complete annual HEDIS requirements.
  • Participate in utilization review and quality management programs.
  • Summarize and analyze data; prepare statistical reports; implement decisions in programs according to revisions in standards.
  • Manage strategic goals of the organization, federal and state law, regulations, and NCQA accreditation standards.
  • Collect, analyze, and maintain data on the utilization of medical services and resources.
  • Prepare and presents monthly utilization management and care management reports to Senior Management, identifying potential areas for improvement.

    • Collaboration and Leadership

  • Collaborate with leaders in Care Management, Population Health, and Quality programs to ensure alignment of clinical operations with organizational goals.
  • Participate in various task force and committee projects as requested.
  • Provide leadership and mentorship to clinical teams, fostering a culture of excellence and continuous improvement.
  • Reasonable accommodations may be provided to enable individuals with disabilities to perform the essential functions.

    • Requirements :

  • Bachelor’s degree in nursing or related field preferred; master’s degree preferred.
  • RN with current unrestricted Massachusetts License.
  • Certification in Coding (CPC / CCS / etc.) or Utilization Management (CPUM / CPUR / CPHM) is a plus.
  • Continuing education requirements are met through the renewal of licensure by the Massachusetts Public Health Department.
  • 3-5 years of clinical experience in acute care settings, such as Med / Surg, ICU, Step-Down, ED / ER, or OR.
  • 3-5 years of experience in Medicare Advantage health plans, managed care organizations, or similar settings.
  • Experience in care management, utilization management, and quality improvement.
  • Familiarity with MCG / Milliman / InterQual criteria for medical necessity and concurrent patient management.
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