Director of Clinical Services – Hybrid
 JOB SUMMARY
The Director of Clinical Services is responsible for oversight of all Clinical Services departments – including Utilization Management, Care Management and oversight of clinical vendors. The Director of Clinical Services works collaboratively with the Chief Medical Officer and is a member of the Senior Leadership Team. This position is accountable for meeting financial and operational performance goals and standards. Directly supervises the Manager of Care Management and Utilization Management
RESPONSIBILITIES
• Responsible for day-to-day clinical operations of the health plan, including care management, care coordination, post transitions of care and transitions of care programs, as well as utilization management vendor oversight
• Responsible for member- and provider-based interventions to improve quality and outcomes of care and reduce avoidable costs
• Supervisory responsibility for the Care Management manager and reporting staff working in Care Management department
• Oversight of all clinically-related compliance reporting and auditing activities
• Responsible for quality and oversight of UM vendor(s)
• Hire, develop and lead a high performing team of clinical and non-clinical professionals that will deliver exceptional care while meeting quality and delivery targets
• Define goals and objectives guiding the delivery of nursing care and ensuring consistent nursing standards
• Develop and implement strategic goals related to population health management and quality improvement, including setting the direction for analytics and development of quality measures
• Interacts regularly with executive team and department heads to ensure Clinical Services operational priorities are aligned with overall company direction and goals
• Work collaboratively with health plan leadership to develop and execute upon KPIs related to cost, quality, operations and outcomes of member care
• Manages and provides monthly reporting, showing utilization and financial metrics for in-patient/out-patient facilities, physicians and ancillary providers
• Strategic planning and execution to ensure established goals are met while improving productivity and efficiency within Clinical Services areas
• Ensures applicable TRICARE and Defense Health Agency (DHA) requirements for clinical services activities and reporting are met
• Works closely with the Quality department to support clinical vendor oversite
• Responsible for budgetary oversight of Medical Management/Clinical services dept
• Collaborates with various departments to support Fraud, Waste & Abuse program
• Collaborates with CMO to maintain the benefit grid and Authorization List
• Maintains UM and clinical services policies
• Maintains familiarity with pertinent MEDICARE and TRICARE regulations, policies, and manuals; especially the TRICARE policy and operations manuals
• Participates in DHA and committees as requested by CMO and Senior Leadership
EXPERIENCE/CERTIFICATION/LICENSE
• Bachelor’s Degree required. Master’s Degree strongly preferred (MSN, MBA, or MPH)
• Registered Nurse in good standing in New York state
• 5+ years’ experience at Director level or higher management position overseeing care management or clinical services in a health plan, clinically integrated network (CIN), management Services organization (MSO), accountable care organization (ACO), risk-bearing IPA or similar organization
Skills/Competencies
• Thorough understanding of best practices for population health management and quality improvement
• Exceptional leadership qualities with strong business acumen and sound decision-making.
• Ability to communicate effectively, verbally and in writing
• Advanced in use of Office 365, Microsoft Word, Excel, Outlook, etc. Proficiency with care management platforms strongly preferred

SALARY RANGE: $185,000.00-$195,000.00