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Clearlink Partners · 11 hours ago

Vice President of Utilization Management (CA Licensed)

United States

Full-time

Remote

Lead/Staff, Director/Executive

$180K/yr - $225K/yr

5+ years exp

Clearlink Partners is an industry-leading managed care consultancy specializing in clinical and operational management services. The Vice President of Utilization Management will design utilization management programs, oversee operational performance, and lead client engagements to ensure effective healthcare delivery and compliance with regulatory standards.

Health Care

Responsibilities

Design utilization management programs, processes and workflows to meet operational goals and anticipate future strategic needs

Evaluate ability to automate and streamline standard work

Analyze and monitor quality, cost reimbursement and utilization trends

Develop and oversee inpatient and outpatient utilization management programs to ensure cost-effective use of patient care resources

Case delivery at the most appropriate level

Collaboration with the medical staff on resource utilization issues

Compliance with utilization-related private contracts, all regulating agencies, and applicable federal and state regulatory mandates

Provide direction for health plan market/ product operational entry, oversight, management and performance improvement

Leverage advanced industry expertise and expert knowledge, grounded in research and industry best practice, to provide high value consulting and advisory services

Deliver innovative, integrated solutions in support of client goals and engagements

Deliver concise, clear interpersonal communication to both internal and external audiences

Influence others to best course of action through advanced understanding of changing business landscapes

Develop or update policies, procedures, processes and workflows as required to support business needs and requirements

Act in interim leadership capacity to provide supervision and oversight for teams and activities in an indirect supervisory model by: Identify opportunities to improve workflow, generate accurate, high-quality productivity, support organizational compliance with requirements and deliver reductions in associated costs with improvement in organizational quality performance in collaboration with Client leaders

Lead engagements, acting as the Engagement Manager, to ensure completion of all contracted services by: Evaluate and ensure completion of integrated project plans

Manage coordination and execution of plan activities to achieve key milestones and meet delivery expectations

Evaluate, write and deliver project reports

Present findings, recommendations and plans to Client executives

Facilitate complicated problem-solving discussions to drive to timely, effective decision making

Advise on risk and benefit discussions to persuade key decision makers and influencers on next steps

Coach and motivate staff to reach established engagement goals, deliverables and KPIs

Adapt processes, approach, plan and/ or activities in real time when project targets, goals or timelines are at risk to ensure critical path activities are achieved

Responsible for the engagement quality, maintaining appropriate resources, competency training and education of staff

Responsible for approving and managing day to day engagement resourcing/ time and attendance for assigned projects/ teams, which can include, but not limited to: Approving paid time off requests, ensuring they don’t put the project at risk

Pre-approving overtime usage

Ensuring team members submit their time by the published deadlines

Validating time entered is accurate (e.g. hours, Pay Type/Time Code, Client/Project/Role) ensuring no risks to billing for that time

Approving any billable expenses ensuring such expenses were pre-approved by Client, comply with Client’s specific expense policy, if applicable, and are reasonable

Oversee compliance with internal client related audits, support Client preparation for external audits and surveys

Facilitate streamlined exchange of information with all levels of Clearlink and client organization(s)

Articulate performance across multiple projects with qualitative and quantitative results/ outcomes

Provide delivery assurance support for engagements with assigned clients

As a solution/ service Subject Matter Expert (SME), identify market trends and develop strategies, goals and plans in response to changing business conditions

Leverage personal, professional network to identify and deliver new key relationships and sales opportunities

Provide market facing thought-leadership through presentations, professional affiliations, and social media

Create and develop Clearlink specific tools, accelerators, intellectual property, and assets to be used in the design, delivery, innovation and building of Company’s expertise and long-term client relationships

Support account management relationships with key client decision makers

Identify opportunities to streamline and/ or automate workflows for accurate, high-quality production and improved results in cost savings, or outcomes measurement

Provide insight into necessary skill sets/ expertise including the screening, identification and management of designated industry resources to support and deliver contracted work

Qualification

Managed care expertiseUtilization management leadershipRegulatory compliance knowledgeProject management principlesHealthcare administration modelsExcel proficiencyCommunication skillsStrategic thinkingTeam managementProblem-solvingInterpersonal communicationAdaptability

Required

Registered Nurse with current unencumbered Compact nursing license

Bachelor's Degree in Nursing, Healthcare Administration or related field, Master's degree preferred

5+ years progressive utilization management leadership experience in health plan operations, delivering results and managing teams and projects in a health plan setting and/or consulting environment; driving complex, multi-faceted, multi-site, application/operational change/improvement programs and activities

3+ years of management experience in a government payor environment at a Director or equivalent level with experience in multiple lines of business (Medicare, Medicaid, Healthcare Exchange, etc)

Proficiency managing complex work in challenging environments through the alignment of resources and prioritization of efforts to ensure on time, in scope project and/or strategic delivery

Managed care industry expertise in trends, innovation, operations, financing, costs, requirements, performance and outcomes

New product/ market design and implementation in the Commercial, Medicare, Medicare Advantage, Medicaid or associated lines of business

New population identification, program design and implementation to support needs/ requirements of increasingly complex memberships while ensuring stable operations and target outcomes

Strong understanding of legal and regulatory frameworks, healthcare administration models, and internal audit procedures

Ability to understand, interpret and educate on complex concepts such as the Knox-Keene Act and HIPAA, regulations such as State's Department of Insurance, Federal and State Health and Human Services and requirements/ standards from CMS, NCQA, and URAC, to ensure compliance with complex regulatory structures

Strategic thinker with ability to produce and manage system-wide change through influence and persuasion

Knowledge of project management principles, methods, and techniques

Ability to organize, prioritize, and manage multiple complex projects simultaneously

Excellent communication skills both written and oral

High proficiency with core office software (Excel, Word, and PowerPoint)