The Director of Clinical Operations oversees the development, planning, implementation, and delivery of Medical Management consistent with Population Health and Managed Care strategies to lead business units in championing system-wide and local market initiatives to achieve the desired operational objectives. This role serves as a liaison to accreditation, state and federal regulatory agencies, ensures activities are consistent with all applicable accreditation, state and federal regulations and contract requirements to appropriately coordinate within the department, as well as with both internal and external customers.
- Bachelor’s Degree in Health Services Administration, or related field required; Masters Degree or equivalent preferred.
- At least five (5) years of progressive experience in Managed Care, preferably at a health plan.
- At least four (4) years of experience managing diverse teams in a professional business setting, preferably with at least four (4) years of clinical or equivalent experience.
- Experience directly leading Managed Care Operations and healthcare administration activities, including account management, proactively and concurrently auditing/monitoring regulatory requirements, and reporting to senior leadership.
- Proven history of developing and implementing strategies/plans to reach business goals using analytical and problem-solving skills to successfully manage multiple complex projects to drive strategic initiatives.
- Solid understanding of data analysis, budgeting and business operations while adapting to technology advances and supporting financial sustainability that pragmatically minimizes cost while maximizing results.
- Experience with CMS program building, leading, and implementing a compliance program.
- Demonstrated adaptability and flexibility to a rapidly evolving business environment.
- In partnership with senior leadership, serves as a subject matter expert to assist in consistently advancing population health programs and managed care operations focused on quality outcomes, total cost of care, and the bottom-line. Provides routine operational performance updates with escalation of issues and recommendations to leadership as appropriate.
- Directs and coordinates high performing teams to drive quality outcomes, cost-effectiveness, clinical analysis and additional key performance targets to consistently achieve strategic organizational goals. Participates in administrative budget development and monitoring for areas of responsibility.
- Provides oversight, coordinate operations, mitigate risk, and implement improvements to achieve operational efficiency and economies of scale to sustain current business while developing/ implementing new opportunities that achieve budget and timeline targets. Oversees all partnerships related to Medical Management responsibilities.
- Directs all medical management and related compliance functions consistent with all regulatory standards. Prepares and analyzes outcomes and utilization reporting with ability to identify utilization patterns to impact real-time decision making and timely program development. Oversees development of medical review policies, procedures, programs, and ensures annual reviews and revision. Serves as organizational consultant regarding medical review process and UM regulations.
- Influences analytical activities to identify trends and potential opportunities to target management of various focused populations while identifying and/or developing operations and program designs that may impact the organization.
- Develops staffing, structures, and processes to ensure all accreditation, state, and federal regulatory standards in addition to service level agreements meet compliance requirements completed in a timely manner. With an understanding of regulatory and legal guidelines, serves as first point of contact for all regulatory and legal matters related to the business in collaboration with Compliance to ensure consistent application across all operational activities.
- Lead teams and service agreements with adherence to protocols and process regulations to ensure best practices in managed care operations: Program Integrity, Risk Adjustment, Quality, Care Management, Provider Resolutions, Provider/Member Appeals and Grievances, and other departments as required.
- Leads team to serve as liaison with providers and office staff for issue resolution, agreement maintenance, education of new programs, services, operational and compliance requirements while developing appropriate reports to monitor, assess, and provide feedback on network activities.
- Builds strong relationships and work collaboratively with business units across the enterprise and external stakeholders to optimize business operations.
- Demonstrates standard of performance (ownership, teamwork communication, compassion) that support patient satisfaction and principles of service excellence.
ABOUT NOVANT HEALTH - NEW HANOVER REGIONAL MEDICAL CENTER (NHRMC)
NHRMC, established in 1967 in Wilmington, NC, is recognized as a preeminent healthcare organization focused on leading our community to outstanding health. We have an 855 bed network of hospitals and multi-specialty physician group practices with more than 200 physicians. With a network of primary, specialty, neighborhood clinics and regional medical centers; you will find our culture is the very definition of best in practice. Join us and find out how many ways NHRMC offers you the chance to focus on what really matters - our patients and community.
At Novant Health, one of our core values is diversity and inclusion. By engaging the strengths and talents of each team member, we ensure a strong organization capable of providing remarkable healthcare to our patients, families and communities. Therefore, we invite applicants from all group dynamics to apply to our exciting career opportunities.
- Member Top 100 Hospitals – In 2016 NHRMC was recognized as a Top 100 Hospital demonstrating significant investment and financial sustainability for the communities we serve.
- Newsweek's 2020 list of Best Maternity Care Hospitals - NHRMC Betty H. Cameron Women's & Children's Hospital was named as a Best Maternity Care Hospital by Newsweek.
- Forbes America’s Best Large Employers 2018 and 2019- Link
- Becker’s 150 Top Places to Work in Healthcare- Link
- Healthgrades Outstanding Patient Experience
Consider a career at Novant Health - New Hanover Regional Medical Center and become part of this award-winning team!