Director, Clinical Services/Regional Clinical Lead - Telecommute - 2024029

UnitedHealth Group

Arlington Virginia

United States

Healthcare - Physician
(No Timezone Provided)

UnitedHealthcare is a company that's on the rise. We're expanding in multiple directions, across borders and, most of all, in the way we think. Here, innovation isn't about another gadget, it's about transforming the health care industry. Ready to make a difference? Make yourself at home with us and start doing your life's best work.(sm)

The Director of Clinical Services and NE Regional Clinical Lead for the Individual Exchanges is responsible for leading clinical services nationally across all 18 Individual Exchange states and regional clinical oversight of the NE states. This role will support the clinical performance management of existing and new expansion states under an aggressive timeline with ambitious growth goals. This includes working closely with UnitedHealthcare Exchange leaders including the Chief Medical Officer and the VP of Clinical Transformation and Operations to identify, articulate, and prioritize initiatives to support clinical program success based on entry strategy for each state, which involves direct collaboration with other enterprise clinical and non-clinical functions.

The Director of Clinical Services and NE Regional Clinical lead will partner closely with key clinical partners including Optum Enterprise Clinical Services, Optum Enterprise Clinical Services, Optum Behavioral Health, Optum Population Health Services, and Optum Medical Benefit Management to ensure optimal performance of the national Exchanges’ clinical and behavioral health model and continuously improve members and providers’ experience. This individual will leverage data and partner with Exchange leadership to develop comprehensive Key Performance Indicators (KPIs) to monitor performance of key Exchange clinical partners and the Exchange markets, including clinical outcome and quality metrics, appeals, member and provider experience, and affordability targets. 

 
In addition, the Director of Clinical Services and NE Regional Clinical Lead will leverage his or her clinical experience to provide guidance to staff and assist staff in navigating the medical management systems to find resources and to answer questions and ensure the best outcomes for complex high needs members. This individual must be able to draw upon a matrixed team to drive complex business processes throughout and across the organization and will be accountable to monitor targeted KPIs for clinical performance, member and provider experience and affordability as well as contractual business requirements. This role will report to the VP of Clinical Transformation and Operations for the Individual Exchanges within Government Programs.

You’ll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges.

Primary Responsibilities:
Clinical Performance Management

  • Collaborate with Operations, Network and Clinical workstreams to address complex clinical operational opportunities with cross functional impacts
  • Drive development and implementation of integrated BH and medical UM and discharge planning and 100% UM of non-OP services
  • Partner with ECS Medical UM and OBH BH UM leaders to drive UM process maps, business requirements, job aids, SOPs etc
  • Partner with ECS and OBH to monitor Out-of-Network gap exception and SCA process and OON Repatriation process
  • Review of all medical and OBH approval and denial letters for compliance prior to implementation of new business
  • Provide oversight and act as single point of contact of MBM, and clinical vendor management
  • Provide clinical support of CM/DM model with Optum Population Health Services
  • Provide clinical support and monitoring of Appeal’s clinical functional teams
  • Provide clinical support to monitor and drive NCQA and Team Track clinical compliance
  • Assist with IFP clinical model navigation and clinical research-resolution
  • Work with national Health Care Economics teams to develop reports and monitor UM performance

    • Regional Market Lead Management

  • Act as the primary point of contact for clinical issues and questions from C&S and E&I state leaders
  • Partner with the Director of Clinical Benefit Design to support identification of state-specific clinical requirements in each state’s EHB benchmark plan
  • Support Medical Policy team to ensure clinical policies and PA code list are aligned with state requirements
  • Partner with Associate Director of Affordability to identify market trends, utilization, and cost metrics
  • Closely partner with Regional Executive Directors to address complaints to regulators or legislators
  • Support national and state specific affordability initiatives
  • Support state specific quality reporting and quality improvement initiatives

    • You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in

    Required Qualifications:

  • Bachelor’s degree/4-year degree required
  • Clinical background and certification required (Registered Nurse or Licensed Clinical Social Worker preferred)
  • 3+ years experience leading clinical operations and implementing new clinical initiatives for Medicaid and/or Exchange populations
  • Experience presenting on high profile initiatives and results to executive leaders
  • Experience in an affordability or clinical leadership position in a managed care company, public program or organization serving government entities
  • Solid knowledge of any and/or all of the following: NCQA accreditation, HEDIS measures, STARS rates, and Quality operations
  • Understanding of metrics, trends and the ability to identify gaps in care
  • Ability to successfully work in a matrix management environment, with a proven track record of building and maintaining effective internal partnerships that lead to external client satisfaction
  • Ability to quickly build and maintain strong relationships across diverse functions and leaders including market leaders and health plan CEOs and CMOs, C&S affordability leads, United Health Network, and CSP Facets configuration team
  • Ability to lead and motivate people to achieve agreed-upon results, with a focus on driving disciplined, fact-based decisions and executing with discipline and urgency
  • Ability to balance multiple accountabilities and organizational change
  • Appreciation for the individuals served by state and public healthcare programs
  • Strategic thinking and business acumen with the ability to align strategies and recommendations with clinical operations objectives. Adaptable and flexible style of collaborating with key stakeholders in setting direction

    • Preferred Qualifications:

  • Advanced degree (e.g., MBA, MPH or other related degree)

    • UnitedHealth Group requires all new hires and employees to report their COVID-19 vaccination status.

    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)

    Colorado, Connecticut or Nevada Residents Only: The salary range for Colorado residents is $110,200 to $211,700. The salary range for Connecticut / Nevada residents is $110,200 to $211,700. Pay is based on several factors including but not limited to education, work experience, certifications, etc. In addition to your salary, UnitedHealth Group offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives.

    *All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy

    Director, Clinical Services/Regional Clinical Lead - Telecommute - 2024029

    UnitedHealth Group

    Arlington Virginia

    United States

    Healthcare - Physician

    (No Timezone Provided)

    UnitedHealthcare is a company that's on the rise. We're expanding in multiple directions, across borders and, most of all, in the way we think. Here, innovation isn't about another gadget, it's about transforming the health care industry. Ready to make a difference? Make yourself at home with us and start doing your life's best work.(sm)

    The Director of Clinical Services and NE Regional Clinical Lead for the Individual Exchanges is responsible for leading clinical services nationally across all 18 Individual Exchange states and regional clinical oversight of the NE states. This role will support the clinical performance management of existing and new expansion states under an aggressive timeline with ambitious growth goals. This includes working closely with UnitedHealthcare Exchange leaders including the Chief Medical Officer and the VP of Clinical Transformation and Operations to identify, articulate, and prioritize initiatives to support clinical program success based on entry strategy for each state, which involves direct collaboration with other enterprise clinical and non-clinical functions.

    The Director of Clinical Services and NE Regional Clinical lead will partner closely with key clinical partners including Optum Enterprise Clinical Services, Optum Enterprise Clinical Services, Optum Behavioral Health, Optum Population Health Services, and Optum Medical Benefit Management to ensure optimal performance of the national Exchanges’ clinical and behavioral health model and continuously improve members and providers’ experience. This individual will leverage data and partner with Exchange leadership to develop comprehensive Key Performance Indicators (KPIs) to monitor performance of key Exchange clinical partners and the Exchange markets, including clinical outcome and quality metrics, appeals, member and provider experience, and affordability targets. 

     
    In addition, the Director of Clinical Services and NE Regional Clinical Lead will leverage his or her clinical experience to provide guidance to staff and assist staff in navigating the medical management systems to find resources and to answer questions and ensure the best outcomes for complex high needs members. This individual must be able to draw upon a matrixed team to drive complex business processes throughout and across the organization and will be accountable to monitor targeted KPIs for clinical performance, member and provider experience and affordability as well as contractual business requirements. This role will report to the VP of Clinical Transformation and Operations for the Individual Exchanges within Government Programs.

    You’ll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges.

    Primary Responsibilities:
    Clinical Performance Management

  • Collaborate with Operations, Network and Clinical workstreams to address complex clinical operational opportunities with cross functional impacts
  • Drive development and implementation of integrated BH and medical UM and discharge planning and 100% UM of non-OP services
  • Partner with ECS Medical UM and OBH BH UM leaders to drive UM process maps, business requirements, job aids, SOPs etc
  • Partner with ECS and OBH to monitor Out-of-Network gap exception and SCA process and OON Repatriation process
  • Review of all medical and OBH approval and denial letters for compliance prior to implementation of new business
  • Provide oversight and act as single point of contact of MBM, and clinical vendor management
  • Provide clinical support of CM/DM model with Optum Population Health Services
  • Provide clinical support and monitoring of Appeal’s clinical functional teams
  • Provide clinical support to monitor and drive NCQA and Team Track clinical compliance
  • Assist with IFP clinical model navigation and clinical research-resolution
  • Work with national Health Care Economics teams to develop reports and monitor UM performance

    • Regional Market Lead Management

  • Act as the primary point of contact for clinical issues and questions from C&S and E&I state leaders
  • Partner with the Director of Clinical Benefit Design to support identification of state-specific clinical requirements in each state’s EHB benchmark plan
  • Support Medical Policy team to ensure clinical policies and PA code list are aligned with state requirements
  • Partner with Associate Director of Affordability to identify market trends, utilization, and cost metrics
  • Closely partner with Regional Executive Directors to address complaints to regulators or legislators
  • Support national and state specific affordability initiatives
  • Support state specific quality reporting and quality improvement initiatives

    • You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in

    Required Qualifications:

  • Bachelor’s degree/4-year degree required
  • Clinical background and certification required (Registered Nurse or Licensed Clinical Social Worker preferred)
  • 3+ years experience leading clinical operations and implementing new clinical initiatives for Medicaid and/or Exchange populations
  • Experience presenting on high profile initiatives and results to executive leaders
  • Experience in an affordability or clinical leadership position in a managed care company, public program or organization serving government entities
  • Solid knowledge of any and/or all of the following: NCQA accreditation, HEDIS measures, STARS rates, and Quality operations
  • Understanding of metrics, trends and the ability to identify gaps in care
  • Ability to successfully work in a matrix management environment, with a proven track record of building and maintaining effective internal partnerships that lead to external client satisfaction
  • Ability to quickly build and maintain strong relationships across diverse functions and leaders including market leaders and health plan CEOs and CMOs, C&S affordability leads, United Health Network, and CSP Facets configuration team
  • Ability to lead and motivate people to achieve agreed-upon results, with a focus on driving disciplined, fact-based decisions and executing with discipline and urgency
  • Ability to balance multiple accountabilities and organizational change
  • Appreciation for the individuals served by state and public healthcare programs
  • Strategic thinking and business acumen with the ability to align strategies and recommendations with clinical operations objectives. Adaptable and flexible style of collaborating with key stakeholders in setting direction

    • Preferred Qualifications:

  • Advanced degree (e.g., MBA, MPH or other related degree)

    • UnitedHealth Group requires all new hires and employees to report their COVID-19 vaccination status.

    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)

    Colorado, Connecticut or Nevada Residents Only: The salary range for Colorado residents is $110,200 to $211,700. The salary range for Connecticut / Nevada residents is $110,200 to $211,700. Pay is based on several factors including but not limited to education, work experience, certifications, etc. In addition to your salary, UnitedHealth Group offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives.

    *All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy

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