Highmark Health Director, Clinical Operations - Medicaid, Gateway Health in Pittsburgh, Pennsylvania
This job provides business leadership and administrative oversight, program development, implementation and evaluation of the Utilization Management, Case Management, Outreach and Disease Management Programs impacting health for individuals and populations. These initiatives incorporate the development and monitoring of clinical programs and care initiatives for plan performance and the implementation of population based studies. The incumbent focuses on ensuring enterprise-wide compliance with clinical and service requirements and multi-state regulations.
Perform management responsibilities including, but not limited to: involved in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity.Plan, organize, staff, direct and control the day-to-day operations of the department; develop and implement policies and programs as necessary; may have budgetary responsibility and authority.
Maintain fiscal responsibility for departmental operations; oversight for the development, implementation and evaluation of the department budget; integrate financial information for use in clinical resource management.
Oversight of UM, CM and DM operations to ensure medically necessary services are provided in a timely, cost effective and quality manner and at the appropriate level of care.
Establish operational as well as outcome monitoring systems related to clinical improvement initiatives which includes the analysis andreview of health cost dataand internal/external benchmarks to identify opportunities for clinical quality improvement, cost savings and support of revenue maximization.
Provide effective leadership, strategic direction and business planning for Gateway's Clinical Services department including UM, CM, DM and outreach activities to measure and improve quality of health care provided to members.
Other duties as assigned.
Bachelor's Degree in Health Administration, Public Health or other Medical Degree OR six (6) years' progressive and related experience in lieu of Bachelor degree
3 - 5 years' experience in behavioral health, case management, care management, or disease/condition management
- 5 - 7 years in Management AND 3 - 5 years' in the insurance industry, managed care support, or utilization review OR 1-3 years in Medicare or Medicaid
Master's Degree in Health Administration
Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity