Director of Clinical Operations

3 weeks ago

Northridge, United States CARENATIONAL HEALTHCARE SERVICES, LLC Full time
DIRECTOR OF CLINICAL OPERATIONS
ON-SITE
ENCINO, CALIFORNIA

JOB DESCRIPTION
The Director of Clinical Operations is a California RN licensed nurse, responsible for overseeing all aspects of the Inpatient Case Management operations. The functional responsibilities include both the clinical and technical components of the department.

In collaboration with the Vice President of Clinical Services, plans, develops, and implements all inpatient medical management programs and processes that are consistent with the strategic, operational and budgetary goals of the company.
Works with the Vice President of Clinical Services, Chief Medical Officer or Medical Director, identifies the need for and participates in the development and implementation of Care Management/Utilization Management policies and procedures and ensures compliance as stated below, and to promote cost-effectiveness and improved quality.
Assists with compliance with all health plan, state and federal regulatory requirements (e.g., DMHC, CMS, SNP, NCQA where applicable), including but not limited to Pre- and Post Service Denials and inter-rater reliability surveys and assistance with certain reporting.
Reviews and edits the companies Inpatient and SNF Denial process for errors and omissions to ensure network and company compliance with all applicable state and federal guidelines and laws, and all health plan directives.
Understand all CMS and ICE UM processes/policies/procedures, especially with respect to ICE and CMS denial language and timeliness criteria.
Through inter-departmental auditing identifies areas and staff that require additional development and/or training
Ensures completion of companies UM work plans and semi-annual health plan reports.
Report compliance issues and facilitate resolution.
Works with the Medical Management team to prepare the department for accreditation
Works with the Chair of the UM Committee, and when necessary, the Vice President of Clinical Services, Chief Medical Officer or Medical Director to coordinate activities and Utilization Management Committee meetings.
Provides consultative services and training for internal and external UM participants and facilities.
Is responsible for thorough and timely review and completion of monthly, quarterly and annual audits, and communication of any issues and/or trends requiring additional training and development.
Works with Medical Management team to ensure staff development and regulatory compliance.
Initiates and facilitates interdepartmental participation in UM-related compliance projects, as appropriate, reporting project progress to Vice President of Clinical Services Chief Medical Officer or Medical Director and other key stakeholders as needed.
Plans, directs, assigns and oversees the day-to-day operations of Inpatient Case Management programs including report generation and regulatory compliance.
Interview, hires, evaluates, counsels and terminates employees. Identifies opportunities for improvement and provides additional orientation and skill development on an ongoing basis.
Ensures that all department functions are staffed appropriately and that all departmental processes are completed in a timely and accurate manner on a regular basis.
Monitors and evaluates employee production against established benchmark standards and initiates timely corrective interventions as appropriate.
Develops and implements individual performance goals and objectives for staff on an annual or as needed basis.
Ensures that the Inpatient Case Management processes identify and document all health plan program requirements for optimal pay for performance initiatives.
Develops and implements quantitative program outcomes that cost-justify the continued operation of the program on an ongoing basis.
Develops and participates in the new employee orientation process internally and assists Provider Relations in the orientation of contracted vendors as needed.
Maintains regularly scheduled meetings with the department personnel including 1:1 scheduled, individual meetings with management personnel.
Participates in internal QI Plans, Programs and Activities as directed by the Vice President of Clinical Services.
Provides Administrative Support to the On Call staff and to all after hours service providers
All other duties as directed by management.

REQUIREMENTS
Bachelor’s of Science degree in Nursing (BSN) from an accredited 4-year nursing school, Bachelor’s degree in health sciences or equivalent or Master’s degree preferred
CA RN license
Three to five (3-5) years related experience and/or training; or equivalent combination of education and experience.
Three to five (3-5) years experience in an acute care setting is required.
Five years experience in Case Management, or Discharge Planning required.
Three years of management experience in Case Management required.
Case Management certification (CCM) preferred.
Experience with health plan audits/compliance and NCQA requirements strongly preferred.
CA Driver’s License with clear DMV record and proof of insurance
#CARE6

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