JOB SUMMARY: The Director is responsible for the operations, performance and quality of the Integrated Home Care Division’s Univta Nursing Management Services (UNMS) team and all of their deliverables. This includes the management and leadership of the clinical and support staff in Miramar, FL and Woodbury, MN. The Director will oversee the utilization management process, agency staffing and delivery of both skilled and unskilled home care benefits on behalf of the health plans outside of Florida, to include Medicare, Medicaid and Commercial lines of business. The Director is also responsible to effectively represent UNMS services to internal and external customers and stakeholders and work collaboratively with cross segment and cross functional business unit partners such as infusion services and DME in achieving timely and successful integration of services and new program launches.
Title: Director, Clinical Operations
1. Directs and manages an efficient and effective group of UNMS staff, which serves as the model for service areas outside of Florida and all expansion states. 2. Creates new effective metrics and reports regularly on metrics relating to productivity, quality, compliance with state and federal regulations, and service level agreements. 3. Works with data analytics function to improve and change ongoing information reports to better manage outcomes.
4. Serves as the subject matter expert and liaison with targeted IHC clients on home health services and integrated models which includes ad hoc meetings as well as regular JOC meetings
5. Manages the home health care benefits on behalf of clients. This includes analyzing data and information relative to utilization, health care trends and overall performance of contracts.6. Provides leadership on the integration of infusion, DME and nursing services to provide a more efficient model with more effective service delivery to our client’s members
7. Creates and updates Policies and Procedures to maximize efficiencies and achieve and maintain a URAC accreditation for IHC UM.
8. Assesses program components that need to be developed or changed to meet needs and ensures that these activities will also conform to regulatory and accreditation requirements including URAC.
9. Conducts audits and inter-rater reliability surveys to ensure consistency in clinical and administrative functions.
10. Directly manages, from end to end, the delivery of home care clinical services from initial assessment and intake, to ordering the delivery of services to overseeing the quality and outcomes.
11. Produces monthly and quarterly reports by health plan that will help identify unfavorable service or utilization trends.
12. Serves as the UNMS subject matter expert on the Utilization and Quality Management Committees.
13. Works closely with the Quality and Compliance Department to formulate annual Quality Improvement Projects and to respond to any quality of care or quality of service concerns from regulatory agencies or health plans.
14. Performs on-going assessments and develops long-range plans for the design and upgrade of programs, procedures and systems.
15. Researches, designs and implements new or enhanced care management cost savings programs.
16. Responsible for coordinating efforts between Integrated Home Care and the Transition Care program, including both telephonic and in-home staff.
17. All other duties as assigned
· Associate's degree (RN licensure) in nursing; · 10+ years’ experience in case management and/or utilization management; · 5+ years of progressive management experience including management of direct reports; · 3+ years in the delivery or management of home health services which can include one or all of the following; nursing, DME, infusion services · Current, valid and unrestricted RN licensure.
Additional certifications and qualifications: · Bachelor’s Degree in Nursing or Business (healthcare administration, business, informatics or related field preferred). · CCM certificate · URAC OR NCQA experience in obtaining accreditation and maintaining accreditation
ENVIRONMENT and COGNITIVE /PHYSICAL DEMANDS
· Office environment · Ability to read, hear, speak, keyboard, and reason and problem solve.
· Requires prolonged sitting and telephone usage. · Requires the use of office equipment such as computer terminals, telephones or copiers. · Infrequent lifting up to 15 pounds.
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Univita Health is an Equal Opportunity Employer (EOE/AA) and participates in E-Verify. Univita Health will not discriminate in its employment and employment-related decisions against any applicant or employee based on age, race, gender, creed, religion, national origin, disability, marital status, covered veteran status, sexual orientation, status with respect to public assistance, membership or activity on a local commission, or any other characteristic protected under state, federal, or local law.