Director, Clinical Operations - Medicaid, Gateway Health

Job ID: J111572
Company: Gateway Health Plan
Location: Pittsburgh, PA, United States
Full/Part Time: Full time
Job Type: Regular
Posted at: May 22, 2018

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Description

JOB SUMMARY

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.

ESSENTIAL RESPONSIBILITIES

  • 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 and  review of health cost data  and 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.

MINIMUM QUALIFICATIONS

  • 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

OR

  • 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

PREFERRED QUALIFICATIONS

  • Master's Degree in Health Administration
  • Managed Care
  • Lean/Six Sigma

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
EEO is The Law
Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity (http://www1.eeoc.gov/employers/upload/eeoc_self_print_poster.pdf)
We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact number below.
For accommodation requests, please call HR Services at 844-242-HR4U or visit HR Services Online at HRServices@highmarkhealth.org

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