The Director of Health Care Services (Director), holds a multi-faceted position to include oversight responsibility for Utilization Management, Care Management, and Quality Management service principles and practices, and the establishment of appropriate standards to ensure compliance with policies/procedures, applicable laws, regulatory requirements, and codes of practice pertaining to areas of assigned responsibility. The Director works in tandem with the leadership team to ensure and improve efficiency, quality of care, resource utilization, clinical documentation, service excellence and work-flow processes. The Director is accountable for carrying out compliance training and auditing activities for utilization review, case management and quality management activities. The activities will include creating, training and auditing workflows, integrity report compliance, health plan audit participation and coordination of delegated functions.
• Develop and update policy and procedures and submit for formal Health Services Committee review and approval,
• Implement and monitor Health Services Department functions and responsibilities,
• Prepare and participate in Health Services Committees,
• Coordination between Medical Director, claims, customer service, contracting, and care coordination to ensure all new health plan requirements, contract changes, providers changes are communicated, and training is done with Health Services team,
• Responsible for regulatory audit preparation and participation,
• Oversight of Care Management, Utilization Management, and Quality Management standards and principles,
• Implementation of standard operations procedures to meet contracted health plan and regulatory entity(s) delegation requirements,
• Evaluate and monitor regulatory quality measures, case management, utilization management and service provider expectations,
• Submit analysis and report data for utilization management, care management, and quality monitoring activities to leadership & committee(s), contracted full-service health plans and regulatory oversight entities, i.e. CMS, DHCS, DMHC,
• Conduct ongoing staff trainings regarding regulatory updates, new protocols for UM, CM, and QM, to include NCQA Standards,
• Ensure that Health Service Programs provide for appropriate and cost effective medical, and medically-related services in accordance with application of recognized DHCS, CMS, national criteria sets, and benefit manuals and guidelines,
• Develop communication plans with external providers such as hospitals and State agencies as required to facilitate plan goals and objectives,
• Assist credentialing/re-credentialing ensuring process compliance with accrediting, regulatory, and contractual requirements and that quality metrics are reported accordingly,
• Evaluate and implement changes to medical service functions and performance in relation to company mission, philosophy objectives and policies,
• Manage budget and forecast for strategic planning and key initiatives,
• Meet with regulatory agencies and the other MCO’s to review quality related initiatives.
• Organize and present new concepts, programs and tools to staff and other plan departments.
• Drives quality improvement team and coordinate departmental functions with care management, claims administration, network development, information systems, member services, finance, and the integrated delivery system,
• Drives all claim reports where utilization management or case management reviews are necessary,
• Participate in NCQA, State, and/or other accreditations of the Plan,
• Participates and provides oversite in health plan audits in coordination with quality management,
• Plan, organize and direct the identification, prioritization and implementation of strategic projects that improve financial, service and clinical outcomes for the Health Plan,
• Responsible and accountable for QAPI program activities and for the ongoing maintenance of the Health Plan’s compliance with state regulations, NCQA and other appropriate standards for activities related to quality,
• Responsible for the statistical analysis of utilization data on programs,
• Responsible for Grievances and Appeals in accordance with full-service health plan stipulations and delegation specifications,
• Other duties as assigned.
• Registered Nurse with 7+ years of experience,
• 5+ years managed care experience required,
• 8-10 years of progressively responsible healthcare or clinical experience in a quality management related role,
• Bachelor’s Degree in public health, nursing, pharmacy, or another health-related field or equivalent combination of education and experience. Masters preferred,
• Certification in process improvement (PI) methodologies preferred,
• Clinical background required,
• CPHQ certification preferred,
• Understanding of medical group operations, state and federal/CMS regulations, health plan contractual requirements, and components of an ambulatory quality program, including value-based reporting, is preferred.