Director, Clinical Operations
Posted on: 19 Jan 2021
Omaha, NE
Job Description
Position Purpose:
* Strategically plan for market-specific infrastructure needs, innovative interventions and resource allocation
* Develop clinical initiatives and monitor ICM, UR and disease management programs to ensure appropriate metrics are in place to deliver positive outcomes.
* Develop and maintain departmental policies and procedures
* Develop program descriptions and evaluate programs to meet set guidelines
* Ensure clinical initiatives are consistent with NCQA and state mandates
* Interface across various business unit and corporate departments to ensure effective processes and communication strategies are utilized
Oversee clinical functions in all service areas including: intensive case management (ICM), utilization review (UR), provider training and care coordination. Responsible for clinical initiatives and oversight to ensure processes are consistent with NCQA guidelines as well as state mandates. Ensure the clinical vision and philosophy is conveyed to all staff and supporting integration efforts through interface with Health Plan leadership teams.
Education/Experience:
Masters degree in Behavioral Health or Registered Nurse required. 5+ years of related experience in utilization management or case management.
Licenses/Certifications: Unrestricted license as a LCSW, LMFT, LPC, PhD, PsyD or RN licensed in applicable state(s).
Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.
WellCare
Tampa, FL
WellCare Health Plans, Inc. provides government-sponsored managed care services. The company operates in three segments: Medicaid Health Plans, Medicare Health Plans, and Medicare Prescription Drug Plans (PDPs). The Medicaid Health Plans segment offers plans for beneficiaries of temporary assistance for needy families, supplemental security income, and aged blind and disabled residents; and other state-based programs, such as children's health insurance programs and long-term services and supports programs for qualifying families who are not eligible for Medicaid.
The Medicare Health Plans segment provides Medicare, a federal program that provides eligible persons aged 65 and over, as well as some disabled persons with a range of hospital, medical, and prescription drug benefits; Medicare Advantage, a Medicare’s managed care alternative to the original Medicare program, which offers individuals standard Medicare benefits directly through Centers for Medicare & Medicaid Services; and coordinated care plans that are administered through health maintenance organizations and require members to seek health care services and select a primary care physician from a network of health care providers.
The Medicare PDPs segment provides Medicare part D PDP plans to Medicare-eligible beneficiaries. Its PDP plans offer national in-network prescription drug coverage, including a preferred pharmacy network. As of December 31, 2018, the company served approximately 5.5 million members in the United States. WellCare Health Plans, Inc. was founded in 1985 and is headquartered in Tampa, Florida.
-
IndustryHealthcare
-
No. of Employees12, 000
-
Website
-
Jobs Posted917
