As the organization continues to expand its core service business, the ability to create (and replicate) a best-in-class patient experience thru executional rigor and consistency has never been more important. Managing appropriate level of care determinations across a growing membership base thru both our proprietary and industry-standard Pre-Service UM processes, with the patient and provider at the center of the work, is the starting point for all nH patient journeys in this service line.
The Director of Pre-Service Operations is a senior-level operator responsible for driving standardized, high quality, Pre-Service Utilization Management services across the Health Plan client base. Maximizing resource efficiency, minimizing practice variation, and owning the continued scalability efforts are a few of the important contributions this role will make. The ability to manage between varying needs and differences of each clinical operations team while driving consistency in the delivery model is an absolute must for success in this role.
- Execution and delivery of the centralized Pre-Service Operations organization with focus on driving standardized clinical care management processes and delivery across all market contracts and teams.
- Managing diverse, geographically dispersed, on- and off-shore teams across all Health Plan clients. Leads multiple teams of professional resources focused on driving quality clinical and financial outcomes.
- Drives accountability to performance standards and quality standards across the management team.
- Acts as direct liaison to Clinical Quality, Compliance, and Regulatory functions within our Medical and Health Services Organizations. In this role accountability, you may be secondarily responsible (taking direction from matrixed clinical oversight leaders) for overall Clinical Oversight of the clinical Utilization Management components of the Department.
- Ensures Compliance with all federal and state regulations, accreditation organizations and SLAs.
- Establish meaningful and relevant sub-metrics to further enable assessment of clinical operations team against goals.
- Responsible for ensuring the timely reporting of Contractual UM parameters (SLA) monthly or as otherwise defined to the health plan and market leaders. Supports Sr. Clinical Manager in the understanding of health plan KPI and variation in Preservice UM metrics impacting performance.
- Ensures best practice operational and clinical processes are functioning across the Organization to ensure clinically appropriate care determinations.
- Partners with Health Services, under the direction of the VP, to create clinical stakeholder engagement with market leadership and other key levels of the firm, interfacing when necessary with client partners, and provider organizations to achieve common goals.
- Collaborates with the central Appeals/Denials team, market leadership and medical directors to achieve effective business processes to optimize operational metrics and maintain fidelity to the clinical model.
- Solicits direction and consultation from naviHealth’s clinical resources and organizations, with dotted-line partnership to Health Services, to assist in managing clinical compliance and regulatory needs of the growing Pre-Service Operations Department.
- Proactively models and manages staffing needs in conjunction with team leaders and Executive Leadership.
- Accountable for informing the continued development of performance management and operational analytics tools/platforms to best manage, in real time, a complex, professional workforce.
- Responsible for all contract “production” teams including the Pre-Service Operations Flex Team and Weekend Team.
- Participates in physician, hospital, and ancillary provider education on protocols, policy, and our program.
- Guides the development and implementation of current and subsequent technology platforms aimed at accelerating the teams’ abilities to drive consistent, quality, clinical outcomes through tech-enabled, prescriptive, processes.
- Creates or co-authors with Health Services annual UM documents (program, work plan, policies/procedures, medical necessity criteria, etc.).
- Work in concert with the Director of Support Operations to create process and executional alignment on all interconnected components of the workflow and delivery model.
- Ability to travel up to 10%
- Perform other duties and responsibilities as required, assigned, or requested.
- Bachelor's degree in business, healthcare administration or related field required; Master's degree preferred
- 7+ years experience in operations management, preferably in a healthcare setting
- 5+ years experience leading and building effective teams
- Licensed clinician preferred
- Change management experience and ability to drive success in a fast-paced, growing organization
- Demonstrated knowledge of CMS regulations, healthcare UM landscape, payor and provider organizations.
- Passion for educating, teaching, and partnering up and down the organization to drive engagement and colleague buy-in
- Experience in utilization management, utilization review, and case management
- Experience with process improvement and business process documentation
- Demonstrated ability to research regulatory requirements for clinical sector
- Computer and clinical, care management, EMR, software proficiency
Being a pioneer in post-acute management and care transitions with 19 years of experience, naviHealth is uniquely positioned to manage patients, improve clinical and financial outcomes, and share risk with payors and providers. We provide clinical service support alongside proprietary technology and advisory solutions that empower health systems, health plans and post-acute providers to navigate care episodes across the continuum, with the goal of reducing waste and improving patient outcomes.
We care about the people we serve.
We care about each other.
We care about our communities.
We embrace innovation.
We like simple.
The above statements are intended to describe the general nature and level of work performed by colleagues assigned to this job. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications. naviHealth reserves the right to amend and change responsibilities to meet business and organizational needs as necessary.
naviHealth is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, protected veteran status, or any other protected status under applicable laws and will not be discriminated against on the basis of disability.