Manager, Clinical Teams - Behavioral Health Utilization Management

Job Description

We’re hiring a Manager, Clinical Teams for the Behavioral Health Utilization Management Team! In this critical role, you will collaborate and engage with multiple internal stakeholders and external customers (i.e. providers, vendors, employer groups) to implement population health management and promote a collaborative, integrated culture across lines of business/segments. Supports value-based strategy by leading multiple clinical or non-clinical teams/staff focused on improving member health through proactive and professional services in the following areas: clinical determinations, case management, disease management, wellness, medical policy, medical review, and/or related services.

What You’ll Do

• Assist in the development of operational strategies and innovative solutions for area(s) of clinical oversight; facilitate favorable medical expense, administrative pricing and/or efficiencies.

• Maintain awareness of trends, developments, and governmental regulations in managed health care organizations and product line(s) under leadership purview and recommends associated policy positions, new initiatives and/or existing program changes to improve the company’s competitive position.

• Use competitive intelligence to guide, consult and drive strategic program and product development and management

• Manage the operational performance of multiple integrated clinical functions across multiple lines of business, including Commercial, Medicare and FEP.   Manage Clinical Determinations, Wellness, Medical Policy, Medical Review and/or related services for different line(s) of business to ensure performance standards are met and in compliance with employer groups, FEP Directors’ Office, and/or applicable state and federal regulations.

• Initiate and manage service initiatives/programs to facilitate and promote quality, cost effective outcomes and minimize the impact of fragmented health care delivery on the customers.

• Collaborate and integrate with internal and external customers to deliver a fully integrated care delivery model and seamless member experience and to investigations or escalated/high profile cases; troubleshoot and provide guidance to staff to ensure resolutions and improved customer experience.

• Facilitate and incorporate complex clinical and financial decision making in the day to day operations by presenting thoroughly analyzed cases requiring high administrative approval or intervention.

• Establish and monitor performance and production metrics and goals, including process measures, outcomes measures and financial measures.

• Manage, and/or support implementation of departmental, divisional, or corporate projects that impact the clinical aspects of the service(s) under leadership purview.

• Assist with the evaluation and management of vendor and partnership opportunities.

• Collaborate with the leadership accountable for applicable vendors supporting business area needs.

• Oversee or participate in internal committees relevant to work responsibilities; may represent the department through presentations and/or active participation in cross functional organizational committees

• Implement an integrated continuous quality improvement and change process to assure high quality care, innovation, customer satisfaction and contribution to financial performance of the Program or Operations.

• Responsible for the oversight, compliance, and execution of all regulatory or accreditation activities and processes including the accuracy and compliance of the State, Federal, and other accrediting bodies (i.e. ERISA, DOI, NCQA, CMS).

• Serve as primary contact for compliance and regulatory body audits related to the services under leadership purview.

• Ensure programs and operational changes are communicated to all appropriate internal and external stakeholders in accordance with policies and regulations.

What You Bring

• Bachelor’s degree and 8+ years of relevant experience.

• RN, FNP or other APN certification.  For Behavioral Health specific roles, other applicable licensure will be considered (PhD, LMSW, LCSW, LPC, LMFT, etc).

• Must have valid NC license or multistate compact license.

• 3+ years of direct supervisory or leadership experience.

• Experience in behavioral health focused population health, care management, clinical review or coding, or utilization management in a health care organization/system or health insurance

Bonus Points (preferred qualifications)

• Demonstrated experience managing Behavioral Health Utilization Management Teams

What You’ll Get