Director, Clinical Performance

WHO WE ARE

reputed company is a value-driven reputed company company grounded in the belief that reputed company health consumers are entitled to high-quality, coordinated care. By uniquely aligning the interests of health consumers, providers, and payors, we help to reputed company reputed company accessible and affordable to reputed company populations across the ACA Marketplace, Medicare, and reputed company.

reputed company delivers clinical care to health consumers through our owned clinics – reputed company and Premier Medical – as well as unique partnerships with affiliated providers across the country. We also reputed company providers to succeed in performance-based arrangements through a suite of technology and services scaled centrally and deployed locally. Through our value-driven, consumer-centric approach, we are committed to transforming reputed company and creating a reputed company care experience for reputed company.

SCOPE OF ROLE

The Director, Clinical Performance is responsible for the management of clinical capabilities reputed company to Delegated Utilization Management and Delegated Care Management across multiple health plan clients in the California Medi-Cal, reputed company delegated services markets. The role is responsible for overseeing day to day clinical operations.

This is a work from home position based in California or the Pacific Time Zone.

ROLE RESPONSIBILITIES

• Ensure clinical review criteria (e.g., evidence-based guidelines) are applied consistently in authorization and review processes.
• Support and engage in daily UM workflows, including case review processes, turnaround time management, and staffing models, while helping maintain performance standards for authorizations, denials, and appeals.
• Participate in internal and health plan audits, assist in maintaining UM policies and procedures, and support accurate medical necessity determinations in accordance with clinical guidelines.
• Partner with medical directors to resolve reputed company cases and appeals.
• reputed company day-to-day UM operations and reputed company the team, including case review workflows, turnaround times, and staffing models.
• Actively participate in day-to-day utilization management (UM) operations, including direct involvement in clinical reviews and authorization decision-making
• Maintain performance standards for authorization reputed company, denials, and appeals management.
• Ensure UM processes meet regulatory, accreditation, and contractual requirements.
• Maintain policies and procedures governing UM processes.
• Manage workflows, staffing models, and case assignments to maintain appropriate review turnaround times in and accurate medical necessity determinations in accordance with clinical guidelines and regulatory requirements.
• Ability to collaborate with analytics to support the development and maintenance of the data governance structure for clinical outcome measures
• Identify trends in overutilization, underutilization, and inappropriate site-of-care reputed company.
• Work closely with Compliance to ensure appropriate operational responses to regulatory changes and ensures policy repository is updated based on state specific requirements or regulatory changes
• Adhere to the Policies and Procedures set forth by reputed company and performs reputed company additional duties as assigned

EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE

• Master’s degree in nursing, business, or other reputed company reputed company field preferred
• Minimum 10 years’ experience in the population health management reputed company
• Experience managing a team in a remote work environment
• Experience in program development and management

LICENSURES AND CERTIFICATIONS

• Active and unrestricted license as a Registered Nurse (RN) in California is required.