Director, Clinical Operations for Self Insured Health Plan Job Listing at SutterHealth in Sacramento, CA (Job ID SHSS-1216628)
The primary functions of the SutterSelect Medical Management Director are to enhance and implement the structure and systems to support local management of utilization and quality programs related to a system-wide, ERISA compliant self-insured employee health plans. Such programs include but not limited to medical, network, and disease management. This position requires close working relationships with our affiliates’ clinical leadership as well as with SutterSelect’s TPAs, such as UMR, UBH, and Prescription Solutions.
1. Provides effective administration of Sutter Select utilization, quality, and disease management programs across participating Sutter Health affiliates including strategic planning, project management and fiscal management.
· Develop and implement effective mechanisms for collaboration among the various Sutter Select participating affiliates in relation to plan medical management projects.
· Evaluate clinical and financial data and report to senior management and medical staff leadership with analysis and recommendations on resource utilization, clinical effectiveness and performance improvement.
· Demonstrate effectiveness in establishing system-wide medical management philosophy, goals, standards, and policies to achieve SutterSelect strategic plan and objectives.
· Determines staffing needs. Hires qualified staff, coaches, counsels, and conducts performance reviews.
· Develops and reviews policies and procedures for the functions of medical management.
· Develops a monitoring and measurement system for “customer service” philosophy within medical management.
· Effectively deals with resistance and conflict in work with patients, providers, families and other identified customers, intervening when appropriate to increase cooperation in high-risk, problem-prone situations.
· Monitors utilization trends concurrently and retrospectively and implement plans to improve resource utilization and reduce out of network admissions
2. Ensure utilization and quality management programs are in compliance with all regulatory mandates, rules, and regulations.
· Modify SutterSelect utilization and quality management policies as needed (e.g. compliance with Health Care Reform).
· Update SutterSelect standard medical decision support criteria (eg. Milliman Guidelines).
· Prepare Utilization Management and Quality Management Work Plan and Program Evaluation and update annually.
3. Operates effectively within the Sutter Health system
· Keeps leadership advised on current events which are effective or have the potential to affect the system as a whole.
· Uses system programs, staff and operations as appropriate in working with assigned areas of responsibility
· Assures coordination and communication with Sutter Health affiliates and other functional areas in relation to assigned areas
4. Ensures adherence to policies, procedures and regulations.
· Sutter Health
· Regulatory agencies
· Other SH entities as appropriate
· Stays current in healthcare practices, policies, standards, and trends
5. Other tasks and duties as assigned by CMO or CEO of SutterSelect
Education: Bachelor’s Degree in Business or Health Services or equivalent combination of education and experience. Valid and current California RN license or Master’s degree in management or related field required.
Experience: Significant utilization management and administrative experience in managed care health plans or medical group management as is typically obtained in 5 or more years of increasingly responsible leadership experience. Must have demonstrated ability to develop and implement efficient and effective utilization programs regionally. Must demonstrate experience in program development, project management, staff management, budget development, policy development and effective interrelationships. Experience in development of strategic and business plans and experience in a managed care environment is essential. Experience working within a diverse, matrix management style healthcare system is preferred.
· Knowledge of illnesses, current treatments, and their physical and psychosocial sequelae.
· Knowledge of applicable laws and regulations, government and insurance benefits.
· Knowledge of available health care and community resources appropriate for population served.
· Knowledge of individual and family development over the life span and the influence of cultural and spiritual value in health care.
· Knowledge of statistical data collection techniques, and methods of analyzing and reporting statistical data.
Special Skills: Excellent oral and written communication skills. Ability to influence at all levels, including physicians, administrative leaders, clinical leaders and staff. Analytical ability required. Flexibility in prioritizing responses based on changing needs. Ability to develop and market a strategic/business plan and program development.
Must be able to effectively function in environment involving high-level negotiation activities. Ability and desire to be involved in community activities. Skills in communicating with physicians and other clinical providers. Knowledge of managed care. Excellent grasp of financial issues in health plans; and understanding of ERISA health benefit plans.
Growth Opportunities: Opportunity for additional clinical and administrative responsibilities while exploring the possibility of further clinical integration/management of SutterSelect and Total Health and Productivity Management.
Other: Ability to travel throughout Northern California. Travel may be 25% or more and may vary depending on the needs of the organization. Evening/Night and Weekend meeting attendance may be required. Ability to lift 20 lbs.
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