Provide supervision to clinical staff by overseeing clinical operations in the Utilization Management department. Ensure business strategies, plans, and initiatives are executed/delivered in compliance with governing regulations, internal policies and procedures. The position is responsible for reporting unethical or fraudulent activity related to business operations and adhering to Health New England’s Code of Conduct.
The Clinical Operations Supervisor is responsible for operationalizing initiatives and regulations, using the most efficient and cost effective approaches.
The Clinical Operations Supervisor is the first point of contact for the clinical teams in the Utilization Management department when the UM Clinical Review Nurse is not available.
Accountabilities
Champions a customer focused culture to deepen client relationships and leverage broader Health New England’s relationships, systems and knowledge
Champions a high performance environment and contributes to an inclusive work environment.
Understand how Health New England’s culture and the CX Promise should be considered in day-to-day activities and decisions.
Actively pursues effective and efficient operations of their respective areas in accordance with Health New England’s Values, its Code of Conduct and the Associate Handbook, while ensuring the adequacy, adherence to and effectiveness of day-to-day business controls to meet obligations with respect to operational, compliance, and conduct.
Essential Job Functions
Provide supervision and direction to the clinical staff
Creates an environment in which the team pursues effective and efficient operations of their respective areas in accordance with Health New England’s Values, its Code of Conduct and the Associate Handbook, while ensuring the adequacy, adherence to and effectiveness of day-to-day business controls to meet obligations with respect to operational, compliance, and conduct.
Builds a high performance environment and implements a people strategy that attracts, retains, develops and motivates their team by fostering an inclusive work environment and using a coaching mindset and behaviors; communicating vison/values/business strategy; and, managing succession and development planning for the team.
Promote and enhance the level of clinical expertise of staff
Assist with interviewing, selecting, and training of new clinical staff
Implementing and overseeing clinical operations within the Utilization Management department
Oversees the efficiency of clinical operational processes
Research methods to improve operations and reduce costs
Facilitate meetings with the clinical teams to ensure effective departmental communication.
Monitors the performance, behavior, and attendance of direct reports and provides ongoing feedback to improve performance
Conduct formal monthly one-on-one meetings with all clinical staff. Provide coaching to associates based on quality results and audits, and develop improvement plans when needed. Provide constructive feedback to clinical staff who need improvement, as well as implements performance improvement plans, when necessary.
Conducts annual performance reviews for direct reports, and assists them with creating annual performance goals
Reviews performance trends in order to identify both individual and group training opportunities
Serves as primary back up to the UM Clinical Review Nurse Team Leads
Serve as a liaison to ensure communication to clinical staff on upcoming projects, changes, etc.
Ensure compliance with company policies and regulations
Ensure operational implementation of updates to clinical processes
Maintains a strong knowledge of all UM procedures, across all lines of business, in order to serve as a resource to UM staff to help resolve questions and issues and assist with timely processing of prior authorization requests
Provide clinical support, as needed
Performs other duties as assigned
Reporting Relationships
Manager:
Manager of Utilization Management
Direct Reports:
Inpatient Clinical Review Nurses
Inpatient Clinical Review Nurse Team Lead
Outpatient Clinical Review Nurses
Outpatient Clinical Review Nurse Team Lead
External/Internal Contacts
Internal
Utilization Management Department
External
Health New England Members and Providers
Education / Experience / Other Information
Bachelor’s degree in nursing or higher preferred and a minimum of 5 years of acute and sub-acute care experience, along with a current Registered Nurse license. Moreover, a minimum of four years’ experience performing Utilization Management clinical reviews and knowledge of Medicare and Medicaid regulations is required. Previous leadership experience of 1-2 years preferred.
Highly developed critical thinking skills
Excellent assessment, critical thinking, decision making and organizational skills
Computer literacy and ability to navigate through computer systems
Excellent written and verbal communication skills, including delivering presentations
Excellent time management skills with the ability to manage multiple priorities
Ability to manage an assigned caseload independently
Strong teamwork skills, ability to work collaboratively in consultation with team members
Seniority level
Associate
Employment type
Full-time
Job function
Health Care Provider
Industries
Insurance
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