Ohio Nurses Association

Do you have compassion and a passion to help others? Transforming healthcare and millions of lives as a result starts with the values you embrace and the passion you bring to achieve your life’s best work.(sm)

The Regulatory Adherence Director of Clinical Programs is responsible for planning, organizing, and directing the assigned regulatory operations for the delegated functions of Utilization Management. The Director coordinates duties with appropriate personnel to meet operational program needs, ensures compliance with state and federal health plan requirements, Medicare guidelines and CMS/URAC/NCQA standards; develops and implements policy and procedures; updates and integrates current clinical practice guidelines; performs employee counseling, performance appraisals, and oversights employee training and development.  The success of this position requires the ability to foster communication and teamwork between physicians, market care management team, utilization management staff, corporate departments, vendors, and senior leadership.  This position is responsible for oversight and evaluation of all Clinical Care Management programs.  The Director will assist senior leadership with long-term planning initiatives to maintain operations assuring activities are appropriately integrated into strategic direction, as well as the mission and values of the company.  

Primary Responsibilities:

• Develops audit reporting, participates and provides input and , and impacts outcomes of the following:
  • Regulatory Adherence Sub-Committee
  • Delegation, Readiness, and Compliance Committee (DRCC)
  • Medical Management Committee
• Leads the development, planning and execution of auditing processes
  • Fosters open communication with managers/directors by acting as a liaison between the Training Department(s), the Medical Management Department(s), Quality, and Clinical Programs
  • Identifies and communicates with appropriate departments, teams, and key leadership on internal audit results and/or deficiencies
  • Identifies and communicates gaps between CMS, NCQA requirements and internal documentation audits to appropriate departments, teams, and key leadership
  • Serves as the core liaison to the Health Plan for oversight of delegated activities
• Directs, plans, and supervises activities for all delegated functions in an efficient and effective manner utilizing time management skills to facilitate the total work process
  • Provides constructive information to minimize problems and increase customer satisfaction
  • Spends time mentoring team members, fostering relationship with market operations team, and providing resources for vendor and provider education needs
• Provides effective problem solving, works as a care management clinical programs liaison and resource with all customers internal and external to provide optimal customer satisfaction
  • Maintains current knowledge of health plan benefits and provider network including inclusions and exclusions in contract terms
  • Participates in enterprise activities for execution, monitoring and quality improvement of all care management clinical programs and delegated functions
• Participates in the development, planning, and execution of continual process improvement efforts, policies and procedures, and regulatory compliance functions related to care management activities
  • Coordinates all activities related to delegated and regulatory requirements
  • Develops initiatives for process improvement of care management clinical programs
  • Develops new policies, procedures, job aids, and work flows that enhance operating efficiency of the care management programs or activities
  • Evaluates the success of process improvement efforts and implements solutions for growth opportunities
• Evaluates clinical care management auditor staff performance by providing monthly management level and role level report cards
•  Provides coaching for performance success, recommends merit increases, and consistently executes disciplinary actions/performance improvement plans
• Interviews, hires, and retains quality-licensed staff to meet business needs
• Ensures the timely preparation of reports and records for dissemination to stakeholders to include:
  • Monthly and/or quarterly summary report
  • Monthly and/or quarterly detailed and trending employee report based on Activity/Productivity Tracker
  • Reports of results of Annual Health Plan Audits and resulting risk mitigation activity
  • Weekly reports to stakeholders as required
• Completes and manages regional budget effectively  
• Conducts and/or participates in departmental meetings, patient care coordination meetings, and interdisciplinary team meetings as required for clinical program care management activities
• Conducts annual evaluation of clinical program care management program
• Performs all other related duties as assigned

This is an office-based position located near Interstate Highway I-10 West, near West Frontage Road just past The Rim Shopping Center/Ferrrari Dealership, 78257

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

• Bachelor of Science Degree in Nursing, Management, Business Administration or related field required (or eight years of experience in the managed care, population health management, or utilization management field)
• Registered Nurse with current license in Texas, with compact license for other participating states
• 5+ years of experience in managed care and/or population health management with 3+ years at the management level or above
• Knowledge of federal and state laws and CMS/URAC/NCQA regulations relating to managed care, population management, special needs plan requirements, transition planning and complex care case management
• Knowledge of basic principles and practices of clinical nursing
• Knowledge of referral processes, claims, case management, and contracting and physician practices
• Knowledge of fiscal management and human resource management techniques
• Proficient with computer software programs, to include: word processing, spreadsheets graphics and databases
• In and/or out-of-town travel is required

Preferred Qualifications:

• Master’s degree
• Case Management Certification (CCM) 
• 10+years of experience in managed care and/or population health management field
• 5+ years at a management level
• Ability to effectively plan programs and evaluate accomplishments
• Ability to present facts/recommendations in oral and written form
• Ability to analyze facts and exercise sound judgment arriving at proper conclusions
• Ability to plan, supervise and review the work of professional and support staff
• Ability to apply policies and principles to solve everyday problems and deal with a variety of situations
• Ability to exercise initiative, problem-solving, decision-making
• Ability to establish and maintain effective working relationships with employees, managers, healthcare professionals, physicians and other members of senior administration and the general public
• Effective written and verbal communication skills

Physical & Mental Requirements:

• Ability to lift up to 10 pounds
• Ability to push or pull heavy objects using up to 25 pounds of force
• Ability to sit for extended periods
• Ability to stand for extended periods
• Ability to use fine motor skills to operate office equipment and/or machinery
• Ability to properly drive and operate a company vehicle
• Ability to receive and comprehend instructions verbally and/or in writing
• Ability to use logical reasoning for simple and complex problem solving

Careers with WellMed. Our focus is simple. We're innovators in preventative health care, striving to change the face of health care for seniors. We're impacting 550,000+ lives, primarily Medicare eligible seniors in Texas and Florida, through primary and multi-specialty clinics, and contracted medical management services. We've joined Optum, part of the UnitedHealth Group family of companies, and our mission is to help the sick become well and to help patients understand and control their health in a lifelong effort at wellness. Our providers and staff are selected for their dedication and focus on preventative, proactive care. For you, that means one incredible team and a singular opportunity to do your life's best work.(sm)

WellMed was founded in 1990 with a vision of being a physician-led company that could change the face of healthcare delivery for seniors. Through the WellMed Care Model, we specialize in helping our patients stay healthy by providing the care they need from doctors who care about them. We partner with multiple Medicare Advantage health plans in Texas and Florida and look forward to continuing growth.

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.

Diversity creates a healthier atmosphere: OptumCare is an Equal Employment Opportunity/Affirmative Action employers and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.