- Responsible for the oversight of system wide clinical operations, including Utilization Management, Quality Management, Appeals & Grievances and Clinical Quality Programs.
- Collaborates with the Specialty Benefits, Chief Executive officer and Chief Dental Officer to support the development of a comprehensive clinical model strategy for all products.
Drives execution through direct staff and dotted line business partners of key clinical initiatives supporting the clinical model strategy.
- Development of appropriate business metrics to optimize decisions, clinical outcomes and productivity
- Continual coordination of multiple projects and priorities while keeping internal and external stakeholders informed
- Ensuring quality assurance practices are implemented and upheld; monitor and report on quality in addition to maintaining industry standards
- Partnering with key operations and support teams and leaders to define program requirements, expected benefits, and associated service level agreements are met
- Develop and execute proactive analytics that drive an effective UM program
- Responsible for achieving an affordability agenda
- Monitor and maintain appropriate clinical and non-clinical claim system edits
- Identify and study general and specific utilization trends, and adjust UR program to target services and providers for prospective global claim review
- Develop and maintain a UM program strategy to profile provider utilization, including focused provider review, including UM vendors and consultants
- Research targeted provider utilization based on utilization profile, counsel on their patterns, issue provider report cards, recover funds as appropriate, and refer suspected fraud and abuse for action
- Maintenance of Quality Management Program, Quality Improvement Program
Oversees and ensures the development and implementation of Clinical Quality Programs initiatives to meet or exceed HEDIS & EPSDT quality standards.
- Determination of grievance and appeals and dental process oversight
- Coordinate and monitor provider and site audits for managed care and Medicaid networks as indicated by local regulatory requirements
- Engaging in RFP creation and evaluation and development, negotiation, and monitoring of SOWs associated with external solution vendors
- Development and maintenance of policies and procedures
- Monitoring and maintenance of clinical review guidelines for global and focused review
- Responsibility for regulatory compliance on all dental products and functions
- Liaison with Legal and Product Development on managed care contract, compliance, and regulatory filings
- Create and implement a progressive approach to the UM function, including appropriate staffing and vendor selection
- Recruiting, talent development, and ongoing engagement of professional staff
Bachelor’s Degree in Healthcare or related equivalent
7-10 years managing a dental program or equivalent and clinical and non-clinical staff related to the quality and care management activities
Management and implementation of UM on a national level
Experience with Claim Reviews including Fraud and Abuse
Experience in Quality Management
Experience with Client and regulatory audits
Excellent communication, collaboration, team building and relationship management skills
Successful in obtaining results in a large corporate, matrixed environment
Capable of gaining support for initiatives through influence and use of business rationale
Proven ability to make and implement tough decisions
Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment
UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.