Market Director Clinical Services

About the role

The Market Director of Clinical Services is responsible for achieving clinical, Medical Loss Ratio, and quality goals as outlined in the Longevity Health Quality and Annual Clinical Performance Plans. This role requires the Market Director to be the local market ISNP expert, providing education, support, and coaching to the clinical team, and working in partnership with the local Medical Director and Market President/Vice President.

Responsibilities

• Daily oversight and monitoring of the Model of Care elements/metrics, clinical performance metrics, and quality metrics to ensure clinical program quality and contract compliance.
• Primary authority and responsibility for managing the overall clinical operations and quality functions within the market.
• Facilitating HEDIS and STARs/MTM compliance, communication, and ensuring gaps closure.
• Reviewing and disseminating coding gaps, suspects, and low prevalence reports and ensuring NPs are absorbing and closing as appropriate.
• Makes periodic facility rounds to ascertain relationship status, NP integration, PCP receptivity.
• Oversight authority for any delegated entities delivering LHP clinical services, clinical affordability program.
• Responsible for the overall clinical performance of the market - HEDIS/STARS rating, Admits/1000, Documentation and Coding accuracy, MTM reviews rate.
• Serves as the Risk Manager for the Health Plans.
• Ensures clinical and quality programs are delivered in accordance with state and federal regulations, accreditation standards, and health plan objectives.
• Create and ensure delivery of standards and policies within budgetary guidelines.
• Responsible for the delivery and review of the Annual Quality Improvement Plan, Utilization Management Plan, and affiliated policies, procedures, and staff/vendor training.
• Actively participates in Quality Improvement Committee Meetings and CCIP program.
• Drives market-based and national quality improvement initiatives.
• Participates in Health Plan Clinical Ops, Quality, Delegated Oversight and other assigned Committees/meetings.
• Creates efficient and effective clinical workforce and local supporting clinical and operational processes.
• Responsible with the Account Manager/Market Leader to run the monthly facility meetings with Nursing Home leadership to ensure good working relationships with stakeholders to provide ongoing clinical reviews of hospitalizations and facility metrics and provide follow up interventions.
• Reviews performance metrics and NP scorecard and delivers CAP (in consult with COO).
• Conducts market-based Hospitalization Review Meetings collaboratively with market Medical Director, ensures follow-up actions in place, accuracy of the hospital tracking data.
• Participates in Utilization Management Meetings and reviews, Quality Investigations.
• Leads market clinical performance improvement programs/projects to improve clinical outcomes and develops risk mitigation plans when performance is not on track.
• Engages market Medical Director in education and enhancement of clinician performance and PCP engagement.
• Accountable for market NP and NP Clinical Manager assimilation and retention.
• Leads innovation and special projects aimed at improving member outcomes.
• Develops and implements cost-effective clinical staffing plans and training/support programs to ensure optimal market clinical performance.
• Identifies risks to effective clinical execution and implements plans to mitigate.
• Participates in marketing, budgeting, and forecast process.
• Participates in medical cost management initiatives.
• Effectively collaborates with Market Leader, Medical Director to engage partners, PCPs, and key stakeholders in achieving market targets.
• Creates an environment of efficiency, effectiveness, and avoidance of unnecessary procedures, testing, that may be harmful or that does not improve quality of life for members.
• Where state mandated, ensures NPs have collaborative practice agreements in place and effective oversight monitoring is in place and being done.

Requirements

• Licensure: Licensed as an advanced practice nurse in home state, ANCC or AANP Board certified.
• Valid state driver's license with a good driving record.
• Auto insurance coverage at the minimum required by your state of residence. Proof of coverage will be required at the time of hire and annually on your hire date.
• Education and Training: Master’s Degree in Nursing. Adult, geriatric, family, acute care, primary care OR hospice and palliative, medical psychiatric nurse practitioner education from an accredited school.
• Knowledge and Experience: Clinical background working in nursing homes or supervising staff in nursing homes, Clinical Quality Program design, Utilization Management Plan implementation, working in a managed care plan/risk bearing entity. Leading and managing clinical affordability initiatives. Successful experience in managing a team of professionals (NPs, RNs, etc.) to achieve overall program/health plan goals. Ability to stay on top of trends in the health care industry with particular focus on competitive analysis, growth, innovation and clinical technology. Knowledge of applicable State and Federal regulations, Medicare Advantage Institutional Special Needs Plans Model of Care, STARS-Quality Program requirements and other regulations, NCQA requirements. Nursing home background and experience required. Computer proficiency, including Microsoft Office Suite. Ability to learn and successfully utilize electronic medical records and other clinical software. Ability to compile and analyze data to be used for management, differentiation, and marketing purposes. Excellent verbal and written communication skills. Strong interpersonal skills a must for effectively enhancing relationships with the communities we serve, including the internal organization. Excellent public presentation skills. Highly organized and able to manage multiple projects, people, and deadlines at one time. Able to work independently with minimal supervision getting results in a fast-paced environment. Ability and willingness to follow Health Plan policies and procedures, work as a team member, supporting Health Plan programs and services, and represent Longevity Health Plan in a positive professional manner. Must have strong knowledge of the healthcare community in the assigned market area.

Qualifications

Licensure: Licensed as an advanced practice nurse in home state, ANCC or AANP Board certified.

Education and Training: Master’s Degree in Nursing. Adult, geriatric, family, acute care, primary care OR hospice and palliative, medical psychiatric nurse practitioner education from an accredited school.

Knowledge and Experience: Clinical background working in nursing homes or supervising staff in nursing homes, Clinical Quality Program design, Utilization Management Plan implementation, working in a managed care plan/risk bearing entity. Leading and managing clinical affordability initiatives. Successful experience in managing a team of professionals (NPs, RNs, etc.) to achieve overall program/health plan goals. Ability to stay on top of trends in the health care industry with particular focus on competitive analysis, growth, innovation and clinical technology. Knowledge of applicable State and Federal regulations, Medicare Advantage Institutional Special Needs Plans Model of Care, STARS-Quality Program requirements and other regulations, NCQA requirements. Nursing home background and experience required. Computer proficiency, including Microsoft Office Suite. Ability to learn and successfully utilize electronic medical records and other clinical software. Ability to compile and analyze data to be used for management, differentiation, and marketing purposes. Excellent verbal and written communication skills. Strong interpersonal skills a must for effectively enhancing relationships with the communities we serve, including the internal organization. Excellent public presentation skills. Highly organized and able to manage multiple projects, people, and deadlines at one time. Able to work independently with minimal supervision getting results in a fast-paced environment. Ability and willingness to follow Health Plan policies and procedures, work as a team member, supporting Health Plan programs and services, and represent Longevity Health Plan in a positive professional manner. Must have strong knowledge of the healthcare community in the assigned market area.

Skills

Strong interpersonal skills a must for effectively enhancing relationships with the communities we serve, including the internal organization.

Excellent public presentation skills.

Highly organized and able to manage multiple projects, people, and deadlines at one time.

Able to work independently with minimal supervision getting results in a fast-paced environment.

Ability and willingness to follow Health Plan policies and procedures, work as a team member, supporting Health Plan programs and services, and represent Longevity Health Plan in a positive professional manner.

Benefits

Equal Opportunity Employer.

Pay

Competitive salary commensurate with experience.

Schedule

Full-time position.