Clinical Director, Managed Care (CA Licensed)

Company Description

Clearlink Partners is an industry-leading managed care consultancy specializing in end-to-end clinical and operational management services and market expansion initiatives for Managed Medicaid, Medicare Advantage, Special Needs Plans, complex care populations, and risk-adjusted entities.

We support organizations as they navigate a dynamic healthcare ecosystem by helping them manage risk, optimize healthcare spend, improve member experience, accelerate quality outcomes, and promote health equity.

Position Responsibilities

Specific

• Comprehensive understanding and previous experience overseeing the core principles of managed care: appropriate utilization and medical necessity for benefits and services, advocacy for treatment plans that are appropriate and cost-effective, population health management, quality improvement and outcome achievement, wellness and prevention programs, continuity of care for members, patient education and engagement, identification and remediation of gaps or delays in care/ services
• Conduct service assessments to understand and document opportunities to improve performance
• Leverage assessment findings to develop gap reports and recommendations for decision/ action by the Client
• Understand and make budgetary recommendations based on ROI and associated financial impacts
• Leverage experience/ expertise to observe performance and suggest improvement initiatives
• Ensure understanding of industry standard competencies and performance metrics to optimize decisions and clinical outcomes
• Evaluate individual and team performance meets or exceeds the performance competencies and metrics
• Design/ implement overall department structure such that a) staffing is appropriate and cost-effective; b) technology use is maximized; and c) staff and operational performance standards are met or exceeded
• Design, develop and facilitate understanding, adoption and compliance with Model of Care
• Develop health services programs and processes to meet current strategic needs / anticipate future state innovation
• Conduct post contract award discovery and scope confirmation and planning
• Evaluate and ensure vendors meet obligations and fulfill contractual requirements
• Oversee and direct requirements gathering, workflow development, gap analysis, solution design, software configuration, and related documentation to optimize outcomes and support improved efficiency
• Identify potential gaps between client requirements and needed functionality
• Participate in design and discovery sessions offering best practice insights and recommendations
• Partner with development to define and prioritize client enhancement requests
• Collaborate with technical teams to support system integration and automation
• Collaborate on the development of project plans and deliverables
• Establish an open, collaborative environment ensuring team members understand changes affecting work
• Develop and provide client training and related materials using a train-the-trainer approach
  
  

General

• Provide direction for health plan market/ product level operational oversight, management and performance improvement
• Leverage industry expertise and expert knowledge, grounded in research and industry best practice, to provide high value consulting and advisory services
• Deliver innovative, integrated solutions in support of client goals and engagements.
• Provide delivery assurance support for engagements with assigned clients
• Support or lead engagements ensuring completion of contracted services
• create and/ or manage to project plans
• write proposals/reports
• present to Client executives
• facilitate, advise and persuade key decision makers and influencers
• Deliver concise, clear interpersonal communication to both internal and external audiences
• Facilitate streamlined exchange of information with all levels of Clearlink and client organization(s)
• Articulate performance across multiple projects with qualitative and quantitative results/ outcomes
• Influence others to understand and accept strategies, goals and plans in response to changing business conditions
• Develop methodologies and best practices to be applied across individual account strategies/ client plans.
• Establish goals and track progress to ensure achievement
• Act in interim leadership capacity to provide supervision and oversight for teams and activities in a direct supervisory model
• Identify opportunities to improve workflow, generate accurate, high quality productivity, support organizational compliance with requirements and deliver reductions in associated costs with improvement in organizational quality performance in collaboration with Client leaders
• Develop or update policies and procedures as required to support business needs and requirements
• Identify opportunities to streamline and/ or automate workflows for accurate, high quality production and improved results in cost savings, or outcomes measurement.
• Coach and motivate staff to reach established engagement goals, deliverables and KPIs
• Adapt processes, approach, plan and/ or activities in real time when targets, goals or timelines are at risk to ensure critical path activities are achieved
• Support account management relationships with key client decision makers
• Develop and deploy management reporting, if indicated, to support monitoring and improvement of performance, implementing plans for improvement as necessary
• Responsible for the engagement quality, maintaining appropriate resources, competency training and education of staff
• Responsible for approving and managing day to day engagement resourcing/ time and attendance as an Engagement Manager
• Oversee compliance with internal client related audits, support Client preparation for external audits and surveys

Position Qualifications:

Competencies

• Bachelors Degree in Nursing or other affiliated health care discipline required, Master’s Preferred
• Registered nurse with current unencumbered license
• Experience working with vulnerable populations helpful, knowledge of health disparities highly desired
• Experience managing interdisciplinary care teams in a fast paced, time-sensitive environment
• Ability to participate in collaborative discussions and facilitate joint decision making
• Ability to translate business problems and questions into clear requirements for design and development
• Fundamental conceptual problem-solving skills
• Ability to evaluate gaps and present recommendations for viable options/ alternatives
• Ability to work autonomously and take independent initiative
• Deep expertise in field of study
• Working knowledge of workflow development as it relates to functions performed within managed care plans
• Experience with the implementation and/or support of data conversions or interfaces
• Proficiency managing complex work in challenging environments through the alignment of resources and prioritization of efforts to ensure on time, in scope project and/ or strategic delivery.
• New product/ market design and implementation in the Commercial, Medicare, Medicare Advantage, Medicaid or associated lines of business
• New population identification, program design and implementation to support needs/ requirements of increasingly complex memberships while ensuring stable operations and target outcomes
• Strong understanding of legal and regulatory frameworks, healthcare administration models, and internal audit procedures.
• Work closely with concepts such as HIPAA, as well as State’s Department of Insurance, Federal and State Health and Human Services, CMS, NCQA, and URAC, to ensure compliance with complex regulatory structures.
• Strategic thinker with ability to produce and manage system-wide change through influence and persuasion
• Knowledge of project management principles, methods, and techniques
  
  

Experience

• Current unencumbered CA RN license
• Minimum of 5+ years of acute clinical experience
• 5+ years progressive leadership experience in health plan operations, delivering results and managing teams and projects in a health plan setting and/or consulting environment; driving complex, multi-faceted, multi-site, application/operational change/improvement programs and activities.
• 3+ years of management experience in a government payor environment at a Director or equivalent level with experience in multiple lines of business (Medicare, Medicaid, Healthcare Exchange, etc)
• Minimum 2 years’ experience in a managed care environment across multiple lines of business (Medicare Advantage, Managed Medicaid, Dual SNP, Commercial, etc.)
• 2+ years of care management experience in managed care environment, CM certification preferred
• Strong knowledge of care management/ population health processes and industry best practice
• Detailed knowledge of SDOH frameworks and community resource networks
• HMO and risk contracting experience preferred
• In-depth knowledge of current standard of medical practices and insurance benefit structures.
• Excellent oral and written interpersonal/communication, internal/external customer-service, organizational, multitasking, and teamwork skills.
• Proficiency in Microsoft Office
  

Physical Requirements

• Must be able to sit in a chair for extended periods of time
• Must be able to speak so that you are able to accurately express ideas by means of the spoken word
• Must be able to hear, understand, and/or distinguish speech and/or other sounds in person, via telephone/cellular phone, and/or electronic devices
• Must have ample dexterity which allows entering of text and/or data into a computer or other electronic device by means of a keyboard and/or mouse
• Must be able to clearly use sight so that you are able to detect, determine, perceive, identify, recognize, judge, observe, inspect, estimate, and/or assess data or other information types
• Must be able to fluently communicate both verbally and in writing using the English language
  
  

Time Zone: Eastern, Central, Mountain or Pacific

Other Information

• Expected Hours of Work: Friday 8 am – 5 pm; with ability to adjust to Client schedules as needed
• Travel: May be required, as needed by Client
• Direct Reports: None
• Salary Range: $135,000 - $175,000
  
  

EEO Statement

It is Clearlink Partners’ policy to provide equal employment opportunity to all employees and applicants without regard to race, sex, sexual orientation, color, creed, religion, national origin, age, disability, marital status, parental status, family medical history or genetic information, political affiliation, military service or any other non-merit-based factor in accordance with all applicable laws, directives and regulations of Federal, state and city entities. This salary range reflects the minimum and maximum target wage for new hires of this position across all US locations. Individual pay will be influenced by Experience, Education, Specialized Soft Skills, and/or Geographic location.