Director, Clinical Services (High Cost)

Job ID: J115703
Company: Highmark Inc
Location: Pittsburgh, PA, United States
Full/Part Time: Full time
Job Type: Regular
Posted at: Jan 20, 2018

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Description

JOB SUMMARY

This job directs the development, implementation, oversight and continuous improvement of the systems, processes, policies and staffing necessary to ensure cost effective and consistent management of high cost members and high cost claims.  This includes leading a multi-disciplinary team comprised of disease managers, case managers, utilization management, and analytics employees either through direct or indirect reporting relationships assigned to this specific segment of the Organization's members.  Through a matrix reporting relationship to the High Cost Center of Excellence, the incumbent will ensure attainment of client and/or market-specific operational, clinical and financial commitments that help drive process improvement efforts to better manage and/or design member intervention programs and improve client/account expectations.  Participates as a key driver of the development and execution of corporate strategies for the effective delivery of proactive, innovative and engaging health coaching and case management services. Uses internal analyses and external benchmarking to remain market-competitive and to continuously enhance the services being offered to both group clients and individual members. The incumbent will place specific focus on helping members through the continuum of care in a high quality, effective and cost efficient manner while tracking and being responsible for outcomes.  

ESSENTIAL RESPONSIBILITIES

  • Perform management responsibilities to include, but are 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.
  • Accountable for the strategy and effectiveness of Clinical Services high cost interventions through an indirect reporting relationship to the High Cost Center of Excellence. This could include partnering with analytics and program designers to identify and prioritize opportunities and ultimately see through the change implementation within Clinical Services. Ensure effective processes, including the use of predictive models, for the proactive identification, assessment and engagement of at-risk members in addition to those who are chronically ill. Oversee development and implementation of policies and procedures that meet the changing business needs while ensuring compliance with all applicable CMS, URAC, NCQA, FEP, DOH and DOI standards and regulations.  Complete all required reporting per compliance requirements in professional and timely manner.
  • Collaborate with: Market leaders, and sales to develop and implement solutions for emerging market and client needs including the requirements of CMS; Physician staff in market segment and/or in the clinical function to ensure continuous improvements in the delivery and effectiveness of services and improvement in member outcomes.  Use benchmarking through scientific research, networking and literature searches to continuously raise the expectations of performance and remain competitive with the product offerings of other health plans and care management vendors.
  • Lead a multi-disciplinary team comprised of disease managers, case managers, utilization management, and analytics employees either through direct or indirect reporting relationships.  This involves day-to-day management of the team and co-leading some employees in partnership with peer leaders.  Partner with the Workforce team to develop and manage the appropriate staffing model for direct team as well as teams that report to other leaders who have high cost accountabilities.  Ensures the staffing models align with the need to demonstrate value through member clinical outcomes, care cost savings, etc. relative to the cost of staff.  Responsible for effective on-boarding and training for all staff associated (directly and indirectly) with the clinical high cost team.  Ensure proper training for staff, partnership with reporting and analytics to determine the measurement of change, and effective change management.  
  • Develop and participate in strategic initiatives based on the business needs.  Develop and manage the operational budget.

EDUCATION

Required

  • Bachelor's Degree

Substitutions

  • 6 years of experience as a clinician leader

Preferred

Bachelor's Degree in Nursing

Or

Master's Degree in Nursing


EXPERIENCE

Required

  • 7 - 10 years Management

Including any of the following

  • 7 - 10 years Utilization Review
  • 7 - 10 years Case Management
  • 7 - 10 years Care Management

And

  • 3 - 5 years Health Insurance Industry
  • 3 - 5 years Care Delivery Models

Preferred

  • Registered Nurse
  • Case Management Certification
  • Disease Management Certification 

SKILLS

  • Leading Change
  • Analytical and Logical Reasoning/Thinking
  • Call Center Management/Analysis
  • Business Process Improvement
  • Written & Oral Presentation Skills
  • Influence and Persuasion
  • Resource Management
  • Results Oriented

Travel Requirement

0% - 25%

Position Type

Office-Based

Teaches / trains others regularly

Frequently

Travel regularly from the office to various work sites or from site-to-site

Occasionally

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

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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