By providing leadership of the health plan's Utilization Management (UM) and Quality Review programs, the Director of Clinical Operations will improve the affordability of health care for low income San Francisco enrollees, thereby supporting the financial viability of the community's safety net providers and the long term success of federal/state healthcare reform.
WHAT YOU WILL DO
- Provide tactical and strategic leadership as a member of the Health Services Leadership team, ensuring integration of clinical operations, care management, pharmacy, and health outcomes improvement
- Provide leadership to support the continued evolution of an effective discharge planning/care transitions program, specifically the development of an on-site staff model and key hospital partners
- Lead and cultivate the company culture, values and integrity within the SFHP managed care organization. Support the organizational health model: creating cohesive teams, achieving service excellence, and serving with respect
- Contribute to the evolving integration of clinical operations with other Health Services departments: care management, pharmacy, and health outcomes improvement; establishes department objectives and metrics in alignment with organizational goals, and support management in reaching these goals
- Manage and continuously improve the Utilization Management process to maintain full compliance with state regulatory requirements and relevant NCQA accreditation standards
- Develop and implement UM process redesign and programmatic improvements to improve efficiency, quality, performance, and reduce administrative expense without compromising results and customer service
- Provide oversight of the quality management team, which includes a dedicated RN for UM delegation oversight, provider dispute resolutions, and clinical grievance review/potential quality incident investigation
- Streamline workflows and optimize the skills of the nursing team through mentoring and management of the Prior Authorization and Concurrent Review Nurse Manager (all staff work to the top of their license; we optimize efficiency and service)
- In collaboration with the Performance Process Improvement and Claims department, provide subject matter expertise to direct claims system (QNXT) redesign to facilitate automated claims payment and reduce need for manual reprocessing of submitted claims and authorizations
- Ensure adequate departmental staffing is in place while you set and maintain high standards for hiring
- Interface directly with the Plan IPAs/medical groups, community programs, state programs and hospitals to ensure coordinated, continuous cost-effective quality health care for members
- Maintain collaborative ongoing relationships in support of the managed care organization with internal and external entities and partners
WHAT YOU WILL BRING
- A current unrestricted California RN license
- At least 5 years of leadership and management experience
- Knowledge of and experience with managed care programs and California/federal insurance programs (Medi-Cal/Medicaid preferred)
- Must have direct management experience with large-scale initiatives involving significant dollar amounts and implications, a large staff, and involving diverse stakeholder groups
- Expertise in Utilization Management
- Expertise in using operational health plan information to ensure high levels of performance and to drive continuous improvement
Established in 1997, San Francisco Health Plan (SFHP) is a an award winning, managed care health plan whose mission is to provide affordable health care coverage to the underserved low and moderate-income residents in San Francisco county. SFHP is chosen by eight out of every ten San Francisco Medi-Cal managed care enrollees and its 145,000+ members have access to a full spectrum of medical services including preventive care, specialty care, hospitalization, prescription drugs, and family planning services. SFHP was designed by and for the residents it serves, and takes great pride in its ability to accommodate a diverse population that includes young adults, seniors, and people with disabilities.
San Francisco Health Plan is an Equal Opportunity Employer (EOE) M/F/D/V
Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.