Clinical Director, Health Plan Operations RN at McLaren Health Care

Flint, Michigan, United States -

Full Time

Start Date

Immediate

Expiry Date

31 Jan, 26

Salary

0.0

Posted On

02 Nov, 25

Experience

10 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Leadership, Medical Management, Utilization Review, Case Management, Quality Improvement, Regulatory Compliance, Policy Development, Training, Clinical Analysis, Performance Management, Cost Efficiency, Communication, Staff Supervision, Health Care, Managed Care, HEDIS

Industry

Hospitals and Health Care

Description

We are looking for a Director, Medical Management, to join us in leading our organization forward. McLaren Integrated HMO Group (MIG) is a fully owned subsidiary of McLaren Health Care Corporation and is the parent company of McLaren Health Plan in Michigan and MDwise, Inc. in Indiana. It is an organization with a culture of high performance and a mission to help people live healthier and more satisfying lives. McLaren Health Plan and MDwise, Inc., subsidiaries of MIG, value the talents and abilities of all our employees and seeks to foster an open, cooperative and dynamic environment in which employees and the health plans can thrive. As an employee of MIG, you will be a part of a dynamic organization that considers all our employees as leaders in driving the organization forward and delivering quality service to all our members. McLaren Health Plan is our Michigan-based health plan dedicated to meeting the health care needs of each of our Michigan members. Learn more about McLaren Health Plan at https://www.mclarenhealthplan.org. MDwise is our Indiana-based health plan, working with the State of Indiana and Centers for Medicare and Medicaid Services to bring you the Hoosier Healthwise and Healthy Indiana Plan health insurance programs. Learn more about MDwise, Inc. at https://www.mdwise.org/. Position Summary: Provides overall management and direction for the assigned Plan's health services and medical management activities to meet organizational goals. Assumes responsibility for the clinical administrative aspects of utilization review and case management. Integrates medical management processes with all departments within the Plan with a focus on ongoing communication. Directs Medical Management processes to be appropriate; compliant with NCQA standards and regulatory agencies and within budget. Develops and implements departmental policies and procedures as well as documentation of the case management and utilization management processes. Responsible to collaborate in the delivery of the Quality Improvement Performance Plan (QPIP) to facilitate that quality standards are met, with a focus on all assigned NCQA standards. Responsible for the selection, training of health care staff, development and implementation of policies and procedures for inpatient, outpatient and ambulatory utilization that result in delivery of medical care in a cost efficient and quality manner. Assists where necessary or through project management those business ventures undertaken by the Company to ensure its profitable future. This is a hybrid position with requirements to come onsite as scheduled, Flint, MI. #LI-AK1 #LI-MV1 Qualifications: Required: Bachelor's Degree in Nursing, health care or business-related field Valid RN License in state doing business in Ten (10) years' experience in a progressively more responsible leadership role in managed care leading utilization, case and/or quality management with demonstrated experience involving clinical and quality analysis and direct interaction with health care providers with at least fou r(4) years' experience in a management role with direct reports, leading or assisting in all phases of effective supervisions (i.e.. recruitment, performance management, training) Three (3) years' clinical experience in a licensed field May require weekend supervision for staff Preferred: Professional certification in related areas (i.e. Case Management, HEDIS) Fifteen (15) years' experience and knowledge of Managed Care functions (e.g. medical delivery, regulatory compliance, HEDIS, NCQA) Affiliation with a Professional Organization

Responsibilities

Provides overall management and direction for the assigned Plan's health services and medical management activities. Directs Medical Management processes to ensure compliance with standards and budgetary constraints.