Clinical Operations Manager

About the role

This position is responsible for managing Clinical Operations, including assuring medical and dental authorizations for members are processed timely and according to regulatory requirements. This position is also responsible for managing care coordination services assuring a personalized, timely, comprehensive, and cost-effective approach to the provision of medical and dental health related services. This position is responsible for overseeing compliance of state and federal requirements for associated work, including contractual requirements with the Medicaid plans by performing the following duties.

Responsibilities

• Manages the medical and dental utilization review processes for members.
• Leads the management of contract deliverables and compliance related to utilization management and care coordination.
• Demonstrates knowledge of the Medicaid benefit packages and the ability to administer those benefits.
• Leads the process for identifying members with catastrophic, complex, and chronic medical management needs and leads assessment and delivery of potential options and alternatives for management of specific health related needs.
• Oversee the coordination of care across a continuum of care settings to assure appropriate care and achievement of optimal outcomes.
• Manages the processing of authorization requests for dental, medical specialty and ancillary referrals, hospitalization authorizations, durable medical equipment, skilled nursing facility placements, inpatient rehabilitation, long term care stays, and home health services.
• Oversees the determination of appropriate level of care and quality of care and collaborates with the team to identify alternative levels of care for members.
• Works with the Director of Clinical Operations and Chief Medical Officer in reviewing complex cases and authorization requests.
• Ensures a coordinated approach to care planning and appropriate use of healthcare resources.
• Supports the