UCare offers Medicare, Medicaid, Individual and Family health plans powered by the hardest working people in the industry. Our people powered teams de-complicate, advocate and always go the extra mile to help our members. We serve with integrity, compassion and commitment to do right by members, providers and government partners. Above all, we come to work excited to provide members a path for the best health of their lives.
WORKING AT UCARE
Working at UCare is more than a career; it's a mission. A mission that defines us as professionals, unites us as an organization and shapes how we interact with our members and each other. Employees join UCare and stay because of the opportunity to have a purpose-driven job.
Our strong culture has established UCare as a Star Tribune Top 150 Workplace for 10 consecutive years since the awards program began. It's a culture that embraces innovative ideas, strategic partnerships, and exemplary customer and provider experiences. Working at UCare is being a part of a people powered team dedicated to making a real difference in the lives of our members and communities.
CLINICAL SERVICES DIRECTOR - OPERATIONS
This position is responsible to complete complex tasks and make decisions within broad parameters with minimal supervision. Oversee the operational aspects of non-direct clinical services, orientation & training, project coordination, and process improvement within the Clinical Services Department. Responsible for the development and implementation of utilization management and health coaching programs and services. Provide leadership, direction and support for services to ensure best practice is employed to achieve quality outcomes, reduce/contain costs, and shape and interpret the standards required to ensure a high level of member and medical director satisfaction and a high degree of employee engagement. Oversight is provided for staff education & training and delegate communication related to utilization management.
Provide leadership and mentoring to assigned operations area managers/supervisors, while assuring successful regulatory compliance and supports performance management of staff.
Provide back-up coverage in absence of managers/supervisors.
Oversee day-to-day administration and management of the utilization management and health coaching services. Consult with the Vice President, Clinical Services and make recommendations for clinical services business functions related to direct report areas.
Maintain knowledge and understanding of managed care policies, regulatory requirements, and key payer and provider contract provisions as related to utilization management and health coaching.
Collaborate with clinical services leaders and medical directors to facilitate effective chronic condition programming and ensures interventions are employed and that complex cases are referred, reviewed and managed appropriately, such as PCA.
Monitor overall utilization management effectiveness, consults with medical directors and other key stakeholders to review and facilitate effective utilization management programming and interventions to ensure medical expense remains within established benchmarks.
Maintain knowledge of relevant laws (ex: Data Privacy Act), regulations and ensure team updates department and/or organization policies as appropriate.
Oversee the development of systems and policies/procedures to meet regulatory requirements (CMS & DHS) and NCQA standards. Ensure application of policies and procedures that support assigned functional areas.
Develop and maintain assigned budgetary responsibilities relevant to primary areas of oversight.
Chair and/or participate in work groups and committees as assigned.
Ensure orientation and ongoing training as needed to facilitate service delivery and professional growth. Prepare staffing matrixes, monitors and manages staff productivity, and revises staffing plan as appropriate.
Ensure coordination of projects and process improvement activities as requested by the Vice President, Clinical Services.
Participate in the joint selection and orientation of assigned staff to ensure appropriate screening, hiring, and effective selection of staff members.
Represent UCare as an active member of work groups, sub-committees, interactions with regulators, and special projects. Some travel may be required.
Participate as a key member of the Clinical Services leadership team and work collaboratively with the Vice President, Clinical Services and Medical Directors to develop the annual department plan.
Assist the Vice President, Clinical Services to formulate, implement, and evaluate UCare's utilization management programs.
Ensure utilization management and health coaching quality metrics demonstrate continued improvement in the area of Stars/HEDIS measures.
Collaborate with others to engage staff and corrects course as appropriate related to UCare Staff Engagement survey results. Promote positive employee engagement and appropriate communication with staff.
Evaluate member/provider satisfaction with operations business functions and services through annual satisfaction surveys.
Other projects and duties as assigned.
Bachelor Degree in nursing or closely related fields preferred. Associate Degree in the above fields of study with commensurate experience. An unrestricted and current Minnesota licensure in field of study (as appropriate).
Seven years clinical practice experience in a health setting. Five years progressively responsible management/supervisory experience that has included analyzing and recommending solutions for development utilization management and health coaching. Comprehensive knowledge of Medicare and Medicaid rules/regulations related to utilization management services.
Knowledge of utilization management and health coaching models and principles.
THE UCARE DIFFERENCE
The UCare difference is our people power employees actively working on the behalf of our members to get them access to the health care they need. We value and respect each individual's ideas and contributions, and provide the freedom to grow both personally and professionally. We are centrally located, and offer onsite education, equipment and wellness resources, and a myriad of volunteer activities. If you're looking for an inclusive environment that celebrates your people power, helps you build on your strengths and gives you the opportunity to truly make a difference, we invite you to apply.
As an Equal Opportunity/Affirmative Action Employer, we welcome and employ a diverse employee group committed to meeting the needs of UCare, our members, and the communities we serve.