Health Services Director - Metairie, LA
The Health Services Director (HSD) provides strategic leadership and is accountable for all clinical programs for all products and membership served by the health plan to ensure contractual compliance and achievement of clinical and utilization management goals. The HSD serves as the primary point of contact and is accountable for all aspects of health plan clinical and utilization management performance. Because of the unique structure and alignment of clinical programs within United Healthcare, the HSD role requires a high degree of coordination with external and internal business partners, including, but not limited to the UHC-Clinical Services inpatient and Intake/Prior Authorizations, Appeals and Grievance, Quality, Optum case and disease management, Healthy First Steps, NICU, Behavioral Health, and other clinical specialty, external vendors or national programs.
The Health Services Director must work collaboratively with the health plan Director of Quality and Plan Medical Director to support achievement of state quality initiatives, HEDIS measures and to ensure compliance with relevant requirements of the state's annual Performance Review(S) conducted by the External Quality Review Organization (EQRO), state or other oversight body and meeting NCQA requirements. Additionally the Health Services Director will work collaboratively with the Plan Medical Director, business partners and Finance to develop, implement/execute the Healthcare Affordability Plan, monitor outcomes of the planned initiatives and adjust the Plan as needed to meet targets.
The Health Services Director must possess a solid knowledge of all lines of business, product and cohorts within the health plan operations from a clinical standpoint. This includes TANF, ABD, Complex Care or LTC, CHIP and DUAL Medicare programs.
Specific Responsibilities Include:
- Is accountable for overall local market health plan clinical operations for all products including achievement of annual clinical, quality/affordability and utilization management goals.
- Leads, coaches/develops, trains (in conjunction with clinical learning team) and supports health plan based clinical team. Ensures effective, compliant, clinical program delivery, monitors performance and clinical outcomes.
- Contributes to the development and execution of overall health plan strategies, Winning Priorities Key Initiatives through active participation in Health Plan Sr Leadership/Operations meetings and health plan functional meetings
- Ensures adherence to state contracts for all medical management/clinical requirements and holds business partners/shared services teams accountable for compliance. Has monitoring and controls in place to regulatory measure and monitor performance.
- Identifies and addresses any contractual risks early and implements a performance improvement plan with CM/DM and UM partners to become contractually compliant.
- Works with Health Plan Medical Director to establish strong provider relationships, promote/support the development of ACOS, PCMH initiatives and other provider engagement strategies.
- Collaborates with Medical Director and Shared Services Partners on the development and implementation of medical cost management programs to achieve Health Care Affordability initiatives per Health Plan Business Plan including supporting the PCMH model in targeted Health Plans.
- Is accountable for medical cost reduction goals for Inpatient & Outpatient for all product lines at the local health plan
- Attends regularly scheduled UM rounds to assist with removal of barriers to members with complex discharge needs and address any other barriers
- Fosters/supports social responsibility activities within the Health Plan/UHG and local community
- Actively embraces United Culture and Values in working with both internal and external customers/partners.
- Undergraduate degree or equivalent experience.
- Current unrestricted RN licensure in Louisiana.
- Experience working in Medicaid managed care
- 5 years Care Management/Utilization management experience
- Managed Care Experience
- Health Plan Experience
- Prior supervisory responsibility required, prior management of remote, field-based teams strongly preferred
- Strong written and verbal communication required
- Proficient in Microsoft Office products, including Word, Excel, and PowerPoint
- Ability to manage change in a dynamic, fast-paced environment
UnitedHealthcare Community & State is part of the family of companies that make UnitedHealth Group one of the leaders across most major segments of the US health care system.
If you're ready to help make health care work better for more people, you can make a historic impact on the future of health care at UnitedHealthcare Community & State.
We contract with states and other government agencies to provide care for over two million individuals. Working with physicians and other care providers, we ensure that our members obtain the care they need with a coordinated approach.
This enables us to break down barriers, which makes health care easier for our customers to manage. That takes a lot of time. It takes a lot of good ideas. Most of all - it takes an entire team of talent. Individuals with the tenacity and the dedication to make things work better for millions of people all over our country.
You can be a part of this team. You can put your skills and talents to work in an effort that is seriously shaping the way health care services are delivered.
Diversity creates a healthier atmosphere: equal opportunity employer M/F/D/V
UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment. In addition, employees in certain positions are subject to random drug testing