Hybrid Director, Clinical Programs chez Nexus

Description

The Director, Clinical Program oversees the day-to-day clinical aspects of the review process, ensuring the quality and integrity of clinical processes within the organization. This role requires strong clinical expertise, leadership skills and a deep understanding of commercial healthcare regulations and standards. This role combines project management with hands-on leadership of clinical teams, ensuring compliance, performance and client satisfaction. 

Requirements

Essential Job Functions:

•  Provide clinical guidance and direction to the ProPeer clinical nursing team and serves as escalation point for clinical guidance.
•  Partner with SVP, Medical Management to optimize departmental strategies and ensure alignment with ProPeer’s clinical goals and quality standards
•  Lead and manage daily clinical operations, including personnel, resources and workflows, to ensure efficient and effective medical reviews
•  Ensure productivity, audit compliance, turnaround times and quality standards are met
•  Assist in the creation and delivery of clinical educational programs to ensure continuous clinical excellence across departments
•  Support the development of new educational content and auditing systems to evaluate the performance of nurses and physicians in training, offering constructive feedback for improvement
•  Provide hands-on support during training to ensure adequate coverage and clarification of complex clinical issues
•  Establishes, evaluates, and monitors clinical processes, policies, and procedures
•  Assist in the development and implementation of quality assurance processes to monitor accuracy and consistency of clinical reviews
•  Contribute to the development and revision of clinical policies and procedures related to the review process
•  Provide training and education to nurses and reviewers on clinical topics, review guidelines and best practices
•  Ensures ProPeer clinical team completes work according to regulatory and client specification 
•  Collaborate with other departments within the organization to ensure a cohesive and effective review process
•  Responsible for clinical compliance with all applicable healthcare regulations and standards, including those related to utilization management and independent review, to include URAC and NCQA as well as all state and federal requirements
•  Prepare reports on clinical review activity, quality metrics and other relevant data for internal and external stakeholders
•  Participate with the Director of Operations in overseeing the development and maintenance of reviewer relationships, fostering open communication and collaboration
•  Oversight of clinical workflow and production expectations
•  Reviews performance against operating plans and standards 
•  Contributes to the development and implementation of the IRO’s strategic goals and objectives
•  Identifies opportunities to improve the IRO’s clinical processes, services and overall performance
•  Clinical account management that results in top-notch client service, as well as a positive work environment, fostering a pattern of long-term staff retention
•  Responsible for clinical onboarding of clients within the operational process and ensuring that staff meet the client contract requirements
•  Develops specific short-term and long-term plans, processes, and programs, together with supporting budget requests 
•  Participates in URAC and NCQA audits in conjunction with the Compliance team
•  Participate in the development and management of departmental budgets and productivity targets
•  Manages human resources utilization, promotes employee satisfaction, supports staff development, and utilizes the progressive discipline process when appropriate
•  Make recommendations for improving effectiveness of policies and procedures.
•  Assumes other activities and responsibilities from time to time as directed.

Knowledge and Abilities Requirements:

•  Proven ability to lead and manage a team of clinical professionals
•  Extensive experience in a clinical setting, preferably with experience in utilization management, appeals and quality improvement
•  Demonstrates ability to independently identify and define potential and/or current issues of concern, collect, and analyze data, establish facts, draw valid conclusions, and exercise discretion and sound judgment.
•  Able to effectively monitor, evaluate and administer the resources of each assigned area and make substantiated recommendations regarding resource allocation needs for future planning purposes.
•  Ability to identify trends through analysis of practices to improve the overall utilization of resources and cost containment.
•  Ability to communicate those trends found through analytical study using a variety of reporting mediums.
•  Proven ability to recruit, train and motivate personnel in order to balance staffing strength with profitability and growth.
•  Ability to make recommendations for organizational change to improve the UM/IRO efforts of the organization.
•  Ability to represent UM/IRO in organizational committees as assigned.
•  Excellent relationship management skills, including a high degree of professional demeanor and non-aggressive assertiveness.
•  Demonstrated ability to problem solve complex, multifaceted situations.
•  Strong organizational and task prioritization skills
•  Strong analytical, numerical, and reasoning abilities
•  Participative management type (advocates team concept)
•  Excellent written and verbal communication skills
•  Computer literacy on Microsoft Office products and database programs

Education and Experience:

•  Minimum 5 years of upper-management commercial health Utilization Management experience
•  Active, unrestricted RN license required
•  Prior experience working within an Independent Review Organization or Managed Care Organization is highly desirable
•  Experience managing remote clinical teams across multiple engagements
•  Proficient computer skills; able to navigate through multiple software systems; knowledge of Microsoft suite of products 
•  Excellent communication, data analysis and problem-solving skills

License and Certification: Active, unrestricted RN license required

Driving Essential: No

Position Demands:

This position requires sitting, bending, and stooping for up to 8 hours per day in an office setting. Ability to lift and move objects weighing up to 10 lbs. Ability to learn technical material. The person in this position needs to occasionally move about inside the office to access file cabinets, office machinery, etc. Must be able to operate a computer and other office productivity machinery such as a calculator, copy machine, printer, etc. The person in this position frequently communicates with guests, team members, and vendors and must be able to exchange accurate information.

Equal Employment Opportunity (Our EEO Statement)

The Company is a veteran-owned Company and provides Equal Employment Opportunities (EEO) to all Team Members and applicants for employment without regard to race, color, religion, sex, sexual orientation, gender (including gender identity), pregnancy, childbirth, or a medical condition related to pregnancy or childbirth, national origin, age, disability, genetic information, status as a covered veteran in accordance with applicable federal, state, and local laws, or any other characteristic or class protected by law and is committed to providing equal employment opportunities. The Company complies with applicable state and local laws governing non-discrimination in employment. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, promotion, discharge, pay, fringe benefits, membership, job training, classification, and other aspects of employment. Team Members who believe they are the victims of discrimination should immediately report the concern to their Supervisor and Human Resources Department. Discrimination and harassment will not be tolerated.

We are committed to creating an inclusive environment for all Team Members and applicants. We value the unique skills and experiences that veterans bring to our team and encourage veterans to apply. 

Disclaimer

The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all responsibilities, duties, and skills required of our personnel. All team members may be required to perform duties outside of their normal responsibilities from time to time, as needed.