Director of Clinical Services & Utilization Management

Title: Director of Clinical Services and Utilization Management

Department: Medical Management

Reports To: Chief Operating Officer

Location: Manhattan, NY – HYBRID

Job Type: Full Time, Exempt

Job Summary

The Director of Clinical Services and Utilization Management is a member of the Senior Leadership Team whose primary concern is facilitating optimal organizational performance for all clinical services at USFHP, to include utilization management and care management. Reporting directly to the CMO, the Director of Clinical Services and Utilization Management oversees daily operations, ensuring all clinical programs and activities work seamlessly to achieve organizational objectives. The Director of Clinical Services and Utilization Management drives process improvements, optimizes resource allocation, and fosters a culture of operational excellence.

Responsibilities

• In coordination with the CMO, provide oversight and guidance for effective day-to-day clinical operations of the health plan, including care management, care coordination and transitions of care programs.
• Improve quality of care, health care outcomes and reduce avoidable costs using evidenced-based member and provider interventions.
• Regularly evaluate and report on vendor effectiveness in executing delegated activities through ongoing oversight and monitoring and ensure adherence to contractual terms.
• Identify learning needs and advocate for training and technical support to properly implement operational policies and procedures; continuously educate and empower managers to inform, train and support all staff members.
• Facilitate the development of knowledge, attitudes, skills, and behaviors necessary for team members to function together with a high degree of engagement and satisfaction, attaining the highest possible levels of effective performance.
• Conduct or oversee routine and/or focused audits of policy and procedure adherence as well as coordinating audits conducted by external sources, such as the Defense Health Agency, URAC, or other regulatory bodies.
• Develop goals and processes that guide the delivery of nursing care, population health management and quality improvement that are in alignment with health plan strategic objectives and ensure consistent, high-quality standards of care.
• Develop clinical and utilization metrics that demonstrate effectiveness of programs and activities.
• Develop a structured surveillance process for identifying clinical process improvement and optimization opportunities.
• Ensure the development, integration, effective management, and sustainability of accurate and efficient systems, and policies and procedures for the department’s operational functions.
• Strategically assess and evaluate courses of action, identifying imaginative opportunities to improve performance, and implement innovative and cost-effective solutions leading to effective change management and business process improvement.
• In collaboration with the IT department, lead the evaluation, selection, and implementation of department-related technology and software that will optimize the member, employee, and provider experience, and facilitate the integration of technology to optimize department operations.
• In collaboration with Human Resources, develop and maintain a compliance training program that ensures employees understand and adhere to laws, regulations, and standards relevant to their roles.
• Ensure applicable TRICARE manual changes and drafts are shared with responsible departments, assisting as needed with the development of policies and workflows to ensure compliance.
• Participate in Defense Health Agency and USFHP committees as required.
• Demonstrate clear, effective, and efficient communications, including the use of effective listening skills and constructive feedback; prepare reports and documents and utilize communication strategies to promote stakeholder understanding; plan and conduct impactful and productive business meetings.
• Demonstrate commitment to the highest standards of ethical responsibility, credibility, objectivity, accountability, and trustworthiness.
• Proactively and continually assess personal strengths and challenges and manage learning and guidance needs.
• Other duties assigned.

Competencies

• Strong advocate for improvement and compliance that ensures personal accountability throughout the department. Ability to discuss, incorporate, and apply effective management techniques and theories in leadership activities.
• Ability to serve as a subject matter expert and thought leader on issues and provide guidance, develop solutions for both predictable and unpredictable events or circumstances, and develop others/teams.
• Ability to proactively engage with department leaders, provide guidance, and set expectations for meeting goals and priorities.
• Ability to develop and communicate a clear vision and strategy for department operations that aligns with the health plan’s goals and objectives, and can anticipate and respond effectively to changes in the external environment.
• Ability to facilitate the development, evaluation, and assessment of current quality improvement plans and introduce new initiatives to contribute to improvements in quality, the member experience, and staff satisfaction.
• Ability to use benchmarking to actively identify clinical improvement opportunities.
• Ability to forecast staffing requirements and patterns to support department growth or shifts in health plan personnel availability.
• Ability to employ competency-based hiring practices to assess candidates’ proven skills, behaviors, and abilities needed to ensure best fit, boost retention, and align hiring with department goals.
• Ability to ensure staffing requirements and patterns meet health plan regulatory/accreditation/compliance requirements.
• Ability to proactively identify compliance issues and provide appropriate solutions based on health plan policy and procedure. Maintain high-level oversight of all health plan risk and corporate compliance related matters.
• Ability to communicate persuasively with leaders and staff in ways that help them embrace the need for taking specific actions to improve the quality of clinical operations. Ability to effectively build coalitions and consensus.
• Ability to set a consistent and strong example for upholding fair and honest ethical and moral standards. Be an advocate for ideas based on facts and experience.

Supervises the Following Department or Program Leaders

Current: Manager of Care Management and Utilization Management (1).
Future: As needed to support department growth or expansion of duties.

Experience/Certification/License

• Five or more years’ experience at a director level or higher management position overseeing care management or clinical services in a health plan, Clinically Integrated Network (CIN), Management Services Organization (MSO), Accountable Care Organization (ACO), risk-bearing IPA or similar organization.
• Proven ability to manage multiple projects and priorities simultaneously.
• Previous experience with development and implementation of health care organizational policies and procedures.
• Deep understanding of healthcare payer operations including care management, provider networks, and regulatory requirements.
• Proven problem solving, program-development, team-building and training skills required.
• Proficiency with care management platforms.
• Registered Nurse in good standing in New York state.

Education

• Bachelor’s Degree required
• Master’s Degree preferred (MSN, MBA, or MPH)

SALARY RANGE: $185,000.00-$195,000.00

SVCMC IS AN EQUAL OPPORTUNITY EMPLOYER – ALL QUALIFIED APPLICANTS WILL RECEIVE CONSIDERATION FOR EMPLOYMENT WITHOUT REGARD TO PROTECTED VETERAN STATUS, DISABILITY, OR OTHER CHARACTERISTICS PROTECTED BY LAW.