Health Services Director - C&S Arizona

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The Director of Health Services is responsible for management and administration of multiple Medical and Clinical Operation Functions. The position coordinates the care and services delivered to selected patient populations and promotes effective utilization of resources.

The Director of Health Services has oversight of Business Partners who perform clinical functions to meet regulatory requirements. Includes: IP Utilization Review, Care Management, retrospective review processes, Intake and Prior Authorization clinical elective case review processes, Transition of care program, Justice Reach In Program, Behavioral Health Coordinator function, annual plans/evaluations/workplans for Medicaid lines of business, and reporting needs, integrated Behavioral health programs.

The Director will report to the VP of Health Services, have direct reports within the department, and provide oversight which tracks adequate service delivery which includes identification of barriers and any gaps in care, and processes in place to monitor member's medical, behavioral health and pharmacy services.

There will be responsibility for program planning and development, implementing, managing and coordinating services according to state contract requirements. Responsible for reviewing the state AMPM and Health Plan Contracts to ensure all requirements are being met in the program. A primary focus is to monitor the clinical activities and advise leadership on improvement opportunities regarding medical expense programs and clinical activities that impact medical expense. Interface with Quality Management regarding HEDIS measures.

The position will attend the monthly HQUM (Medical Management meetings) and present program performance metrics on a regular basis; lead other internal and external regulatory meetings as needed.

Primary Responsibilities:

• Performs oversight of UHC Community Plan Clinical programs
• Monitor quality of care issues according to Plan UM / QA policy and procedures
• Provide feedback to VP of Health Services regarding hospital utilization, case management issues and provider issues. Assists in the development of discharge planning screening criteria for use in the review process to determine the need for post hospital care. Evaluate the effectiveness of discharge plans and follow up care by the Person Centered Care Model.
• Interface with the Clinical Management team as needed
• Works closely with Business Partners to ensure regulatory compliance is met
• Provides monthly statistics and reports on clinical programs
• Assist the VP of Health Services to monitor the effectiveness of Clinical Programs
• Assists with program improvement projects
• Serves as liaison to other health services departments (Case Management, Precert. department, Behavioral health, QM, Pharmacy)
• Possess a global understanding of the Health Services department and coordinates services
• Performs other duties for the department as requested by manager
• Prepare regulatory reports as required
• Complete special projects as assigned
• Demonstrate ability to focus health plan clinical activities toward a strategic direction as well as develop tactical plan, drive performance and achieve targets
• Problem solve skills: the ability to systematically analyze program performance, draw relevant conclusions and implement appropriate courses of action
• Excellent verbal and written communication skills; ability to speak clearly and concisely, convey complex or technical information in a manner that others can understand
• Contributes to developing new programs specific to the state requirements
• Sets team direction, resolves problems and provides guidance to members of their own team
• Adapts departmental plans and priorities to address business and operational challenges
• Overall responsibility for workflow activities & activities for designated teams
• Provides clinical expertise to the clinical team and support staff
• Provides mentorship and training for team members
• Represents the department in assigned Plan committees / meetings
• Assists with all team member Human Resource activities
• Supports excellent employee performance and encourage staff development
• Adhere to ethical, legal / regulatory and accreditation standards to meet business goals and objectives
• Adapt departmental plans and priorities to address business and operational challenges
• Analyze utilization reports and develop departmental specific action plans
• Communicate with providers and members as needed
• Develops and submits Provider and Member educational materials
• Ensures clinical teams meet established performance metrics and performance guarantees
• Adapts departmental plans and priorities to address business and operational challenges
• Strategy development with execution
• Establishes product, service or process decisions that will impact multiple groups of employees and / or customers (internal or external)
• Proven history of driving operational performance and achieving established metrics
• Excellent communication skills with the ability to interrelate with individuals at various levels
• Ability to develop effective business relationships across business and product teams
• Ensures all reporting needs both internal and external are available for performance reviews and monthly / annual reporting
• Assist in completing the Annual UMMM Work Plan, UM Evaluation document and MM / UM Program Description document for submission to the regulators

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:

• Current Arizona Registered Nurse license
• 5+ years of professional level clinical experience
• 5+ years of team lead, supervisory, and / or management experience
• Advanced computer proficiency (MS Word, Outlook, Internet, Visio)

Preferred Qualifications:

• Analytical skills

The salary range for this role is $106,800 to $194,200 annually based on full-time employment. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with al minimum wage laws as applicable. In addition to your salary, UnitedHealth Group offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with UnitedHealth Group, you'll find a far-reaching choice of benefits and incentives.

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.

UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

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