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The Health Services Director (HSD) provides strategic leadership and is accountable for all clinical programs for all products and membership served by the health plan to ensure contractual compliance and achievement of clinical and utilization management goals. The Statewide HSD serves as the primary point of contact and is accountable for all aspects of health plan clinical and utilization management performance. Because of the unique structure and alignment of clinical programs within United Healthcare, the Statewide HSD role requires a high degree of coordination with external and internal business partners, including, but not limited to the UHC-Clinical Services inpatient and Intake/Prior Authorizations, Appeals and Grievance, Optum case and disease management, Healthy First Steps, NICU, Optum Behavioral Health, state Medicaid partners and other clinical specialty, external vendors or national programs.

The Statewide Health Services Director must work collaboratively with the health plan Director of Quality and Plan Medical Director to support achievement of state quality initiatives, HEDIS measures and to ensure compliance with relevant requirements of the state's annual Performance Review(S) conducted by the External Quality Review Organization (EQRO), state or other oversight body and meeting NCQA requirements. Additionally, the Statewide HSD will work collaboratively with the Plan Medical Director, business partners and Finance to develop, implement / execute the Healthcare Affordability Plan, monitor outcomes of the planned initiatives, and adjust the Plan as needed to meet targets. The Statewide HSD must possess a solid knowledge of all lines of business, product, and cohorts within the health plan operations from a clinical standpoint. This includes TANF, ABD, CHIP and DUAL Medicare programs.

If you are located in the state of North Carolina, you will have the flexibility to work remotely* as you take on some tough challenges.

Primary Responsibilities:

• Leadership (Measured through performance metrics, Colleague Reviews)
• Overall local market health plan clinical operations for all products including achievement of annual clinical, quality/affordability and utilization management goals
• Local market SME for all clinical/medical management programs and contractual requirements
• Lead, coach/develop, trains (in conjunction with clinical learning team) and support health plan based clinical team. Ensure effective, compliant, clinical program delivery, monitors performance and clinical outcomes
• Contribute to the development and execution of overall health plan strategies, Winning Priorities Key Initiatives through active participation in Health Plan Sr Leadership/Operations meetings and health plan functional meetings
• Foster and promote two-way communication and information sharing necessary for successful clinical program implementation. Act as the Primary liaison to clinical business partners both internal and external for member/clinical issues such as the state Medicaid agency, Optum HFS/NICU, Optum Care Solutions which includes Case Management and HARC, Prior Authorization, Intake, UBH, Appeals & Pharmacy Departments - point of contact for reporting, troubleshooting, case reviews, member complaints and issues requiring local health plan support
• Identify network gaps and access issues and participates in local market Network Management Governance meetings to ensure issues are addressed
• Working in conjunction with Medical Director, ensure regularly scheduled interdisciplinary team meetings and processes are in place to address member and provider issues/needs
• Serve on the Health Plan HQUM and may chair or co-chair as needed. Report clinical metrics and reports into QMC and PAC meetings. Develop & maintain UM/CM annual work plan, program description, and program evaluations
• Develop strategies internally and with business partners for clinical management during high volume provider termination, new membership growth/expansion-ensuring member continuity of care and transition of care needs are met according to the RFP response/contractual requirements
• Conduct regular staff meetings with local Health Services staff and service partners as appropriate, to exchange corporate and health plan information/updates and address staff questions and concerns, etc
• Ensure timely communication of any new contractual requirements, audit findings or business expansion opportunities to the National Clinical Team and Shared Services Partners to ensure appropriate planning and implementation (including resource needs, timelines, IT needs, etc.)
• Implement team initiatives associated with making UnitedHealthcare a great place to work, including embracing Our United Culture and sustaining a highly engaged work force as measured by the annual Vital Signs Survey
• Work in partnership with National Clinical Leadership to develop clinical staffing, clinical model, IT changes/requests to ensure funding, timely approval and execution
• Escalate clinical performance issues to National Clinical Leadership as needed if unable to affect change locally
• Ensure national and corporate service partners achieve established performance metrics and are aligned with health plan strategies and annual operating plans
• Oversee State specific clinical functions to ensure compliance with State regulatory requirements and works collaboratively with the Clinical Adherence team to ensure adherence with regulatory and contractual requirements
• Understand the clinical services for Medicaid and Medicare line of business and/or cohorts contracted within the Health plan including Complex Care programs, as well as members with developmental disabilities
• Compliance/Adherence (Measured by adherence monitoring results, CAPs, Fines, Sanctions related to CM, UM, DM)
• Ensure adherence to state contracts for all medical management/clinical requirements and hold business partners/shared services teams accountable for compliance
• Regulatory measure and monitor performance through monitoring and controls that are in place
• Identify and address any contractual risks early and implement a performance improvement plan with CM and UM partners to become contractually compliant
• Communicate timely, any changes in clinical contractual requirements, Clinical CAPs, sanctions or fines to National Medical Management Leaders/Business Partners and ensure changes are made to business processes to adhere to changes requirements
• Lead the development and implementation with business partners, of health plan specific policies & SOPs to support UM/care management strategies and contractual requirements, CM interventions, and administrative functions and ensures regular review and maintenance processes are in place
• Utilize national policies, procedures, SOPs as the basis for developing or adapting for state specific requirements
• Lead and ensure adoption and delivery of nationally approved policies, procedures, guidelines, and standards for health plan based clinical staff and (and business partners). Conduct local clinical documentation reviews and monitoring to ensure compliance with requirements
• Attend Clinical Governance Leadership meetings - monitor reports for outcomes and alignment with health plan targets and regulatory compliance
• Promote ease of use of the Interdisciplinary Team review process so it is used by clinical staff to address member complex issues, conduct secondary review process for LTSS and/or HCBS care plans and address barriers to service delivery and ability of member to achieve goals
• Work in partnership with local compliance to support Medicaid and Medicare (if appropriate) Fair Hearing and SAP Process
• Knowledge of each line of business (Medicaid, Medicare, Developmentally Disabled) and cohort operation results and develop improvement plans as appropriate
• Customer Relationships (Measured by observation, feedback from external customers and Vital Signs Engagement scores)
• Actively participate in State and Provider meetings in collaboration with the Health plan leadership, CMO
• Actively participate in community outreach and networking activities to develop support and community infrastructure to meet member needs, promote membership growth and retention
• Work with Health Plan Medical Director to establish solid provider relationships, promote/support the development of ACOs, PCMH initiatives and other provider engagement strategies
• Foster/support social responsibility activities within the Health Plan/UHG and local community
• Actively embrace United Culture and Values in working with both internal and external customers/partners
• Participate in member advisory boards as appropriate for all lines of business i.e. Medicaid and Medicare
• Collaborate with Medical Director and Shared Services Partners on the development and implementation of medical cost management programs to achieve Health Care Affordability initiatives per Health Plan Business Plan including supporting the PCMH model in targeted Health Plans
• Augment national initiatives with local initiatives in order to achieve HCAI targets
• Monitor performance and work with shared services/benefits partners to enhance initiatives as needed to meet goals
• Medical cost reduction goals for Inpatient & Outpatient for all product lines at the local health plan
• Review clinical scorecard monthly/quarterly at the health plan level (shared with Inpatient Team Director)
• Attend regularly scheduled UM rounds to assist with removal of barriers to members with complex discharge needs and address any other barriers
• Develop line of sight on quality initiatives and strategies for all products within the health plan and work collaboratively with Quality and Health Plan leadership team to improve HEDIS, CAHPs, HOS, STARs Ratings and other quality performance standards established by state and federal customer
• Work collaboratively across all business segments to design and develop innovative programs to impact Healthcare Quality and Affordability

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:

• NC Licensed Clinician (e.g. LCSW, RN, MD, DO) residing in the State of NC and 5+ years of demonstrated care management/population health experience in a large healthcare corporation serving Medicaid beneficiaries
• Significant experience in development and execution of clinical programs in public sector managed care environment
• Clinical experience with Medicaid/Medicare populations
• Demonstrated track record of clinical program compliance, functional collaboration, and meeting program goals
• Demonstrated track record of leadership development
• Intermediate or higher level of proficiency with MS Office Suite: PowerPoint, Excel, Word, SharePoint

Preferred Qualifications:

• CCM Certified
• Medicaid Managed Care experience
• Field based case management program implementation and monitoring

*All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy

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: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer 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.

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