Director Clinical Operations
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Wilmington, DE 19806
Gateway Health Plan
Job Description :
This job provides assistance with clinical leadership and administrative oversight, program development, implementation and evaluation of the Long Term Services and Supports (LTSS) department impacting health for individuals and qualified populations. These initiatives incorporate the development and monitoring of clinical programs and care initiatives for plan performance. The position focuses on ensuring enterprise-wide compliance with clinical and service requirements and state regulations.
+ Perform management responsibilities including, but not limited to: involved in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity. Plan, organize, staff, direct and control the day-to-day operations of the department; develop and implement policies and programs as necessary; may have budgetary responsibility and authority.
+ Oversight of LTSS clinical operations to ensure medically necessary services are provided in a timely, cost effective and quality manner and at the appropriate level of care.
+ Establish operational as well as outcome monitoring systems related to clinical improvement initiatives which includes the analysis and review of health cost data and internal/external benchmarks to identify opportunities for clinical quality improvement, cost savings and support of revenue maximization.
+ Provide effective leadership, strategic direction and business planning for Gateway’s LTSS Clinical Services activities to measure and improve quality of health care provided to members.
+ Other duties as assigned.
+ Bachelor’s Degree in Health Administration, Public Health or Other Medical Degree
+ 6 years progressive and related experience in lieu of Bachelor degree
+ Master’s Degree in Health Administration
+ 3 – 5 years in LTSS, Case Management or Care Management OR
+ 5 – 7 years in Management
To Include any of the following:
+ 3 – 5 years in Management Care Support
+ 3 – 5 years in the Insurance Industry
+ 3 – 5 years in Utilization Review
+ 1 – 3 years in Medicare
+ 0 – 1 years in Medicaid
LICENSES or CERTIFICATIONS
+ Registered Nurse
+ Analytical and Logical Reasoning/Thinking
+ Communication Skills
+ Analysis of business problems/needs
+ Highly Organized
+ Collaborative Problem Solving
+ Department Budgeting
+ Excellent Multi-Tasker
+ Managed Care
+ Lean/Six Sigma
Language: (Other than English)
0% – 25%
PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS
Teaches / trains others regularly
Travel regularly from the office to various work sites or from site-to-site
Works primarily out-of-the office selling products/services (sales employees)
Does Not Apply
Physical work site required
Lifting: up to 10 pounds
Lifting: 10 to 25 pounds
Lifting: 25 to 50 pounds
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement : This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy.
Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
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Req ID: J142309