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Job Category:

Medical and Clinical Operations

Country:

US

Approximate Salary:

Not Specified

Position Type:

Full Time

Assoc. Health Services Dir. – UHC Comm. Plan NJ

UHG - Iselin, New Jersey

Posted: 12/17/2018

The Associate Health Services Director (AHSD) works under the direction of the Director of Health Services and provides strategic leadership and is accountable for all clinical programs for all products and memberships served by the health plan to ensure contractual compliance and achievement of clinical management goals. This includes TANF, ABD, Complex Care or LTSS, CHIP and DUAL Medicare programs, as well as members with Developmental Disabilities.
 
The AHSD serves as the primary point of contact to the clinical and non-clinical teams and is accountable for all aspects of the health plans clinical performance.  Because of the unique structure and alignment  of clinical programs within United Healthcare, the AHSD role requires a high degree of coordination with external and internal business partners, including, but not limited to the UHC-Clinical Services inpatient and Intake/Prior Authorizations, Appeals and Grievance,  Quality, Optum case and disease management, Healthy First Steps,  NICU,  Optum Behavioral Health,  state Medicaid partners  and other clinical specialty, external vendors or national  programs.
 
 The AHSD must work collaboratively with the health plans, Director of Health Services, Director of Quality and plan Medical Director to support achievement of state quality initiatives, state mandated programs and to ensure  compliance with  relevant  requirements  of the state’s annual Performance Review(S) conducted by the External Quality Review   Organization (EQRO), state or other oversight body and meeting NCQA requirements.  
 
Primary Responsibilities:
 
Is the local market SME for all clinical/medical management & state mandated programs (DCP&P, Lead, Healthy First Steps & Private Duty Nursing) and contractual requirements
  1. Leads, coaches/develops,  trains  (in conjunction with clinical learning team) and supports health plan based  clinical team. Ensures effective, compliant, clinical program delivery, monitors performance and clinical outcomes.
  2. Contributes to the development and execution of overall health plan strategies, Winning Priorities Key Initiatives through active participation in Health Plan Sr Leadership/Operations meetings and health plan functional meetings.
  3. Fosters and promotes two-way communication and information sharing necessary for successful clinical program implementation. Is the Primary liaison to clinical business partners both internal and external for member/clinical issues such as the state Medicaid agency, Optum HFS/ NICU, Optum Care Solutions which includes Case Management  and   HARC,  Prior Authorization,  Intake,  UBH, Appeals & Pharmacy Departments- point  of contact for reporting, troubleshooting, case reviews, member complaints and issues requiring local health plan support.
  4. Identifies network gaps and access issues and participates in local market Network Management Governance meetings to ensure issues are addressed.
  5. In conjunction with medical director, ensures regularly scheduled interdisciplinary team meetings and processes are in place to address member and provider issues/needs.
  6. Leads in collaboration with UHCCS and Optum business partners in audits such as the External Review Quality Organization Audits for clinical programs which may include developing/owning program material binders, policies and responses.
  7. Conducts regular staff meetings with local Health Services staff and service partners as appropriate, to exchange corporate and health plan information/updates; address staff questions and concerns, etc.
  8. Ensures timely communication of any new contractual requirements and audit findings.
  9. Implements team initiatives associated with making UnitedHealthcare a great place to work, including embracing Our United Culture and sustaining a highly-engaged work force as measured by the annual VitalSigns Survey.
  10. Oversees State specific clinical functions to ensure compliance with State regulatory requirements and works collaboratively with the Clinical Adherence team to ensure adherence with regulatory and contractual requirements.
  11. Respond to all State and Regulatory agency inquiries and member grievances
  12. Understands the clinical services for Medicaid and Medicare line of business and/or cohorts contracted within the Health plan including Complex Care programs, as well as members with developmental disabilities.
  13. Attends regularly scheduled UM rounds to assist with removal of barriers to members with complex discharge needs and address any other barriers.
  14. Conduct performance reviews with all clinical and non-clinical staff
  15. Attend State Meetings as necessary
  16. Conduct onsite-supervision of staff members home visit with members
  17. Other duties as assigned
 
Compliance/Adherence (Measured by adherence monitoring results, CAPs, Fines, Sanctions related to CM, UM, DM) 
  1. Ensures adherence to state contracts for all medical management/clinical requirements and holds business partners/shared services teams accountable for compliance. Has monitoring and controls in place to regulatory measure and monitor performance with staff.
  2. Identifies and addresses any contractual risks early and implements a performance improvement plan with CM and UM partners to become contractually compliant. Communicates timely, any changes in clinical contractual requirements, Clinical CAPs, sanctions or fines to National Med Mgt Leaders/Business Partners and ensures changes are made to business processes to adhere to changes requirements.
  3. Works in partnership with local compliance to support Medicaid and Medicare (if appropriate) Fair Hearing and SAP Process.
  4. Knowledge of each line of business (Medicaid, Medicare, Developmentally Disabled) and cohort operation results and develops improvement plans as appropriate.
Customer Relationships (Measured by observation, feedback from external customers and Vital Signs Engagement scores)
  1. Actively participates in State and Provider meetings in collaboration with the Health plan leadership, Director of Health Services & CMO.
  2. Actively participates in community outreach and networking activities to develop support and community infrastructure to meet member needs, promote membership growth and  retention.
  3. Works with Health Plan Medical Director to establish strong provider relationships,
  4. Fosters/supports social responsibility activities within the Health Plan/UHG and local community.
  5. Actively embraces United Culture and Values in working with both internal and external customers/partners.
  6. Participates in member advisory boards as appropriate for all lines of business i.e. Medicaid and Medicare. 

Required Qualifications:
  • A registered nurse having at least (5) years’ experience providing care coordination to persons receiving Medicaid services and an additional three (3) years’ work experience in managed care
  • Clinical experience with Medicaid/Medicare populations
  • Demonstrated track record of clinical program compliance, functional collaboration, and meeting program goals
  • Demonstrated track record of leadership development  
  • Intermediate computer skills – MS Office Suite: PowerPoint, Excel, Word      
 
 
Preferred Qualifications:
  • Advanced degree
  • Medicaid Managed Care Experience
  • Field based case management program implementation and monitoring
  • CCM Certified
 
 
Careers at UnitedHealthcare Community & State. Challenge brings out the best in us. It also attracts the best. That's why you'll find some of the most amazingly talented people in health care here. We serve the health care needs of low income adults and children with debilitating illnesses such as cardiovascular disease, diabetes, HIV/AIDS and high-risk pregnancy. Our holistic, outcomes-based approach considers social, behavioral, economic, physical and environmental factors. Join us. Work with proactive health care, community and government partners to heal health care and create positive change for those who need it most. This is the place to do your life's best work.(sm)

Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.

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