MedStar Medical Group Job - 49435763 | CareerArc
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Company: MedStar Medical Group
Location: Washington, DC
Career Level: Executive
Industries: Not specified

Description

General Summary of Position
The AVP of Clinical Operations coordinates and communicates with providers, members or other parties to facilitate optimal care. This role oversees the clinical and non-clinical staff within the District of Columbia (Maryland) Medicaid areas of utilization management, care management and process improvement. Decisions are typically related to the implementation of new/updated programs or large-scale projects for the function and supporting technical/operational and external relationships in a manner that conveys high credibility and confidence. The highly qualified candidate must be flexible, adaptable, able to manage competing priorities, and be a leader of both people and process.


Primary Duties and Responsibilities

  • Acts as the System Administrator for the care management software system. Able to identify issues with the software, coordinate training, and coordinate testing for system upgrades. Acts as a resource to staff and outside vendors using the software.
  • Develops department goals, objectives, policies, procedures, performance and productivity standards. Ensures compliance with policies and procedures and governmental and accreditation regulations. Oversees the development of policies and procedures for the Clinical Operations department. Updates policies at least annually. Complies with governmental and accreditation regulations.
  • Actively participates with annual strategic planning objectives for MedStar Family Choice. Initiates innovative ideas and programs to improve quality while maintaining or reducing medical expense. Acts as a resource for clinical issues. Ensures that utilization management and case management programs timeframes are in compliance with local, federal and NCQA standards.
  • Oversees monthly monitoring and identify trends of critical data on LOS, Days per 1000, re-admissions, emergency department utilization, physician denials, denial rates at acute facilities, and other reports as required by MedStar Family Choice Senior Management. Responsible for the department operating budget and ensures that department operates within budget.
  • Coordinates with the Chief Medical Officer/Medical Director and is responsible for the oversight of the annual audits; ie EQRO, NCQA, etc. Oversees the development of the annual Clinical Operation plan and Clinical Operations appraisal.
  • Identifies needs within the network. Works closely with provider relations and the contracting to develop contractual relationships with providers and vendors. Oversees the provisions of a range of targeted clinical services and benefits.
  • Provides Clinical Operations department oversight for the Delegated Vendors. Reviews quarterly reports, ensuring adherence to NCQA guidelines and local governmental regulations. Provides information for provider education concerning authorization rules, case management objectives and disease management programs. Identifies issues within the network and reports and corrects the issues promptly.
  • Provides ongoing individual coaching and support to staff and acts as a resource for clinical, social, utilization and appeal review issues as they relate to the Clinical Operations department. Meets regularly with department members to enhance communication and facilitate implementation and progress towards program objectives. Assists staff members to set personal and educational goals and objectives to enhance their professional development. Oversees training program for new staff and is responsible for maintaining an up-to-date training manual for each area of the Clinical Operations department.
  • Responsible for ensuring that the Clinical Operations department is adhering to NCQA guidelines for UM and Complex Case Management programs. Oversees Conducts periodic chart audits to evaluate adherence especially on the
  • Oversees the Care Coordination and Case Management operations ensuring delivery of quality health care, to meet the needs/preferences of the Enrollees, and to support the most efficient use of services through Care Coordination and Case Management activities, including Enrollees with complex medical and/or Behavioral Health needs for the District of Columbia.
  • Responsible to coordinate and conduct studies for the various quality measures required by the District of Columbia regulatory guidelines and NCQA. Evaluates member satisfaction with CM, and makes modifications as necessary to improve satisfaction.
  • Selects, trains, orients and assigns department staff. Develops standards of performance, evaluates performance, and conducts performance management planning. Initiates or makes recommendations for personnel actions. Maintains ongoing communication with subordinates to review programs, provide feedback, discuss new developments and exchange information.
  • Serves as the Clinical Operations key personnel and expert for all State partner or District meetings and encounters.
  • Works collaboratively with the Information Systems Team, Data Analyst and report writers to develop reports to meet the department's annual objectives. Uses technology to enhance decision making and effectiveness.
  • Oversees the organization's utilization management function, pre-certification functions, and management of pharmacy benefits to ensure the appropriate allocation of resources and optimal quality care in the most cost-effective manner is provided.
  • Oversees the selection of departmental staff. Develops standards of performance, evaluates performance, and conducts performance management planning. Initiates or makes recommendations for personnel actions. Maintains ongoing communication with subordinates to review programs, provide feedback, and discuss new developments and exchange information. Coaches and assists other managers with their development.
  • Participates in multidisciplinary quality and service improvement teams as appropriate. Participates in meetings, serves on committees and represents the department and hospital/facility in community outreach efforts as appropriate.
  • Performs other duties as assigned.
  • Oversees and provides clinical direction for Appeals, Retrospective Review and Emergency Department Review (as applicable) and Enrollee Grievances. Ensures that retrospective events, appeals, and grievances timeframes are in compliance with NCQA, EQRO, District of Columbia, Federal, and any other applicable standards.

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    Minimum Qualifications
    Education

    • Bachelor's degree Accredited School of Nursing required
    • Master's degree Related field preferred

    Experience

    • 8-10 years Technical experience to include Utilization Management and/or Case Management; If in DC, District of Columbia Certified Case Manager required
    • 8-10 years Leadership/management exerience required
    • 5-7 years Experience within the organization healthcare services organization preferred
    • 5-7 years Varied clinical experience in hospital or managed care setting required

    Licenses and Certifications

    • RN - Registered Nurse - State Licensure and/or Compact State Licensure Valid RN license in the state of Maryland Upon Hire required
    • CCM - Certified Case Manager Upon Hire preferred

    Knowledge, Skills, and Abilities

    • Must be willing to travel for provider facing and corporate meetings as conditions require/permit.
    • Knowledgeable in utilization review, medical terminology, appropriate levels of care, treatment modalities, statutes, and healthcare delivery models
    • Experience working with Medicaid populations.
    • Demonstrates a high degree of organizational skill and time management for multiple competing priorities.
    • Demonstrates an ability to quicky adapt and mange through a changing environment.
    • Demonstrates ahigh level of emotional intelligence and ability to develop rapport.
    • Demonstrates the ability to manage a large work force and effective navigate change.
    • Excellent clinical, communication, management and leadership skills. Basic computer skills preferred.


    Why MedStar Health?
    At MedStar Health, we understand that our ability to treat others well begins with how we treat each other. We work hard to foster an inclusive and positive environment where our associates feel valued, connected, and empowered. We live up to this promise through:

    • Strong emphasis on teamwork - our associates feel connected to each other and our mission as an organization. In return, our effective team environment generates positive patient outcomes and high associate satisfaction ratings that exceed the national benchmark.
    • Strategic focus on equity, inclusion, & diversity - we are committed to equity for all people and communities. We continue to build a diverse and inclusive workplace where people feel a sense of belonging and the ability to contribute to equitable care delivery and improved community health outcomes at all levels of the organization.
    • Comprehensive total rewards package - including competitive pay, generous paid time off, great health and wellness benefits, retirement savings, education assistance, and so much more.
    • More career opportunities closer to home - as the largest healthcare provider in the Baltimore-Washington, D.C. region, there are countless opportunities to grow your career and fulfill your aspirations.

    About MedStar Health
    MedStar Health is dedicated to providing the highest quality care for people in Maryland and the Washington, D.C., region, while advancing the practice of medicine through education, innovation, and research. Our team of 32,000 includes physicians, nurses, residents, fellows, and many other clinical and non-clinical associates working in a variety of settings across our health system, including 10 hospitals and more than 300 community-based locations, the largest home health provider in the region, and highly respected institutes dedicated to research and innovation. As the medical education and clinical partner of Georgetown University for more than 20 years, MedStar Health is dedicated not only to teaching the next generation of doctors, but also to the continuing education, professional development, and personal fulfillment of our whole team. Together, we use the best of our minds and the best of our hearts to serve our patients, those who care for them, and our communities. It's how we treat people.

    MedStar Health is an Equal Opportunity (EO) Employer and assures equal opportunity for all applicants and employees. We hire people to work in different locations, and we comply with the federal, state and local laws governing each of those locations. MedStar Health makes all decisions regarding employment, including for example, hiring, transfer, promotion, compensation, benefit eligibility, discipline, and discharge without regard to any protected status, including race, color, creed, religion, national origin, citizenship status, sex, age, disability, veteran status, marital status, sexual orientation, gender identity or expression, political affiliations, or any other characteristic protected by federal, state or local EO laws. If you receive an offer of employment, it is MedStar Health's policy to hire its employees on an at-will basis, which means you or MedStar Health may terminate this relationship at any time, for any reason.


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