The Statewide Health Services Director (HSD) provides strategic leadership and is accountable for all clinical programs for all products and membership served by the health plan to ensure contractual compliance and achievement of clinical and utilization management goals. The Statewide HSD serves as the primary point of contact and is accountable for all aspects of health plan clinical and utilization management performance. Because of the unique structure and alignment of clinical programs within United Healthcare, the Statewide HSD 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 Statewide Health Services Director must work collaboratively with the health plan Director of Quality and Plan Medical Director to support achievement of state quality initiatives, HEDIS measures 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. Additionally, the Statewide HSD will work collaboratively with the Plan Medical Director, business partners and Finance to develop, implement/execute the Healthcare Affordability Plan, monitor outcomes of the planned initiatives and adjust the Plan as needed to meet targets.
The Statewide HSD must possess a solid knowledge of all lines of business, product and cohorts within the health plan operations from a clinical standpoint. This includes TANF, ABD, Complex Care or LTSS, CHIP and DUAL Medicare programs, as well as members with Developmental Disabilities.
Leadership (Measured through performance metrics, Colleague Reviews , NCQA Accreditation, performance on state audits, and successful implementations and RFPs, if applicable)
1. Is accountable for overall local market health plan clinical operations for all products including achievement of annual clinical, quality/affordability and utilization management goals.
2. Is the local market SME for all clinical/medical management programs and contractual requirements
3. 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.
4. 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.
5. 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.
6. Identifies network gaps and access issues and participates in local market Network Management Governance meetings to ensure issues are addressed.
7. In conjunction with medical director, ensures regularly scheduled interdisciplinary team meetings and processes are in place to address member and provider issues/needs.
8. 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.
9. Serves on the Health Plan HQUM and may chair or co-chair as needed. Reports clinical metrics and reports into QMC and PAC meetings. Develops & maintains LTSS UM/CM annual work plan, program description, and program evaluations.
10. Is the key clinical leader at the health plan for NCQA accreditation (if required/applicable) preparation and surveys. Works collaboratively with Quality Leader and Medical Director, leveraging National Best Practices/Polices/Procedures, shared services and benefits partners to prepare the documentation and readiness for NCQA accreditation of the local health plan.
11. Develops strategies internally and with business partners for clinical management during high volume provider termination, new membership growth/expansion–ensuring member continuity of care and transition of care needs are met according to the RFP response/contractual requirements.
12. 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.
13. Ensures timely communication of any new contractual requirements, audit findings or business expansion opportunities to the National Clinical Team and Shared Services Partners to ensure appropriate planning and implementation (including resource needs, timelines, IT needs,etc.).
14. 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.
15. Works in partnership with National Clinical Leadership to develop clinical staffing, clinical model, IT changes/requests to ensure funding, timely approval and execution.
16. Escalates clinical performance issues to National Clinical Leadership as needed if unable to affect change locally.
17. Ensures national and corporate clinical service partners achieve established performance metrics and are aligned with health plan strategies and annual operating plans.
18. 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.
19. 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.
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.
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. Leads the development and implementation with business partners, of health plan specific policies & SOPs to support UM/care management strategies and contractual requirements, CM interventions, and administrative functions and ensures regular review and maintenance processes are in place. Utilizes national policies, procedures, SOPs as the basis for developing or adapting for state specific requirements. Leads and ensures adoption and delivery of nationally approved policies, procedures, guidelines and standards for health plan based clinical staff and (and business partners). Conducts local clinical documentation reviews and monitoring to ensure compliance with requirements.
4. Attends Clinical Governance Leadership meetings- monitor reports for outcomes and alignment with health plan targets and regulatory compliance.
5. Promotes ease of use of the Interdisciplinary Team review process so it is used by clinical staff to address member complex issues, conduct secondary review process for LTSS and/or HCBS care plans and address barriers to service delivery and ability of member to achieve goals.
6. Works in partnership with local compliance to support Medicaid and Medicare (if appropriate) Fair Hearing and SAP Process.
7. 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, 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, promote/support the development of ACOs, PCMH initiatives and other provider engagement strategies.
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.
Healthcare Quality and Affordability (measured by affordability metrics, financial results, quality scores, PIP results)
1. Collaborates with Medical Director and Shared Services Partners on the development and implementation of medical cost management programs to achieve Health Care Affordability initiatives per Health Plan Business Plan including supporting the PCMH model in targeted Health Plans. Augments national initiatives with local initiatives in order to achieve HCAI targets. Monitors performance and works with shared services/benefits partners to enhance initiatives as needed to meet goals.
2. Engages and supports identified affordability for medical cost reduction goals for Inpatient & Outpatient for all product lines at the local health plan.
3. Reviews clinical scorecard monthly/quarterly at the health plan level (shared with Inpatient Team Director).
4. Attends regularly scheduled UM rounds to assist with removal of barriers to members with complex discharge needs and address any other barriers.
5. Has line of sight on quality initiatives and strategies for all products within the health plan and works . collaboratively with Quality and Health Plan leadership team to improve HEDIS, CAHPs, HOS, STARs Rating and other quality performance standards established by state and federal customer.
6. Works collaboratively across all business segments to design and develop innovative programs to impact Healthcare Quality and Affordability.
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. Advanced degree preferred.
Significant experience in development and execution of clinical programs in public sector managed care environment
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
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