Role responsible for the design, executive and oversight of the clinical operations teams across all lines of business, including commercial, Medicare Advantage, and Medicaid to optimize care management services delivery to the Triple S membership. Responsible for promoting high standards of clinical excellence through the develop of policies, protocols and practice guidelines. Functions to be managed include preauthorization, hospital review, transition of care, case management, population health and preventive and health education services. Ensures operations are conducted in compliance with URAC, CMS, ASES standards and any other applicable regulation. Leads adherence to program metrics defined in the organizational plan and alters programs as needed to meet targets. Leads daily operations, interprets changes in the marketplace, generates ideas and clinical strategies, evaluates technology and service partners and participates in quality assurance initiatives to increase Triple S market advantage. Interacts at the executive level with internal and external stakeholders to meet business objectives. Essential Functions: Develops, executes and leads the clinical management team of approximately 240 clinical staff members conducting preauthorization, hospital review, transition of care coordination, case management, population health management and preventive health and education services delivery. Conducts annual evaluation of programs with ability to redesign as needed and correspond with regulatory parties. Designs and executes specific line of business programs with metrics to quantify performance Demonstrated knowledge of market trends with an ability to work with the network, product development and clinic teams to migrate population health models into the community. Prepare and manages the budget and daily operations across all lines of business. Review analyses of activities, costs, operations, and forecast data to determine department or division progress toward stated goals and objectives. Operationalizes business projects across all lines of business to meet business objectives. Develops and maintains policies and procedures to meet corporate and regulatory requirements across all lines of business. Participates in regulatory and quality initiatives to ensure compliance. Works with delegated vendors to ensure compliance and performance. Works to identify training and process improvement opportunities and works with the appropriate internal parties to manage delivery of requested programs. Identifies and resolves potential issues and problems early and effectively, readily consulting the Senior Vice or Human Resources Manager and communicating to the other members of the management team as needed. Designs and internal audit program with team to monitor inter rater reliability and designs action plans accordingly. Liaison with Medical Consultants. Manage team performance through coaching, counseling, planning/monitoring, and appraising job results. Other duties as assigned by Sr .
