Director Health Services - SC Medicaid

Profile

Description

The Director, Health Services utilizes clinical nursing skills to support the coordination, documentation and communication of medical services and/or benefit administration determinations. The Director, Health Services requires an in-depth understanding of how organization capabilities interrelate across the function or segment.

Responsibilities

The SC Medicaid Director, uses clinical knowledge, communication skills, and independent critical thinking skills towards interpreting criteria, policies, and procedures to provide the best and most appropriate treatment, care or services for members. Coordinates and communicates with providers, members, or other parties to facilitate optimal care and treatment. Decisions are typically related to identifying and resolving complex technical and operational problems within department(s), and could lead multiple managers or highly specialized professional associates.

The role requires experience caring for patients with complex medical and social needs and an understanding of how to provide care more efficiently and effectively with an interdisciplinary team. We are looking for individuals who are passionate about transforming our care system for patients who need it most and are driven by doing well by doing what's right. This candidate must be an insightful risk-taker willing to thoughtfully disrupt the status quo and excited to work in a rapidly evolving start-up environment.

The role of Director, health services will focus on the following areas:


Serve as a thought leader in designing and then implementing the role of nurses on our interdisciplinary care team
Develop and monitor all clinical protocols, either independently or in collaboration with other interdisciplinary care team members as relevant, for nurses on care team to use for both in person and virtual (both tech-enabled and telephonic) care management, chronic disease management and care at points of transition
Determine state dependent nursing requirements and modify work of the care team as necessary to ensure compliance with all local policies and practices
Oversees the hiring and management of a team of nurses in the market that provide direct member care
Developing and implementing Clinical Prior Authorization policies, processes, detailed workflows, and leading the Centralized Utilization Management Outpatient operations team
Hiring and directly leading a team of Utilization Management nurses and support staff responsible for reviewing and processing clinical authorizations and clinical claims reviews
Assure compliance with state timeframes for turnaround times on authorization requests and delivery of Utilization Management services


Required Qualifications


Active Compact Registered Nurse license in South Carolina, without restrictions or disciplinary action
3-5 more years of leadership experience
7 or more years of technical experience, combination of Utilization Management and Case Management
2 years of Medicaid experience
2 years developing collaborative partnerships with enterprise cross-functional teams
Recent working knowledge and familiarity with Milliman Care Guidelines medical criteria and administering clinical practice guidelines
Demonstrated experience and recommendations from peers as a customer-focused, team player, with collaborative approach to leading
Intermediate to advance computer skills and experience with Microsoft Office specifically Power Point, Word, Excel and Outlook
Previous experience with electronic case note documentation and experience with documenting in multiple computer applications/systems


Preferred Qualifications


Master's Degree
Experience working with Medicare and/or Medicaid populations
Medicaid market implementation experience
Certified Professional in Health Care Quality (CPHQ)
Certified in Health Care Quality and Management (CHCQM)


Additional Information


Position will be Work from Home
Does not need to reside in South Carolina but will need to travel to Columbia, South Carolina as needed
Travel requirement up to 40%


Scheduled Weekly Hours

40

Company info

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