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Job Description:

OVERVIEW OF POSITION:

The Director, Clinical Operations (Director) is accountable for all facets of clinical operations for the Regional Accountable Entity (RAE) contract held by Colorado Community Health Alliance (CCHA) with the Colorado Department of Health Care Policy & Financing (HCPF). Reporting to the Vice President, CCHA, with matrixed reporting to the Program Officer, the Director will provide subject matter expertise on care navigation, coordination and management for Health First Colorado (Colorado’s Medicaid Program) members.

The Director will oversee Care Coordination, Navigation and Management services. This role is accountable for meeting all care coordination and member navigation expectations in the contract, including inbound and outbound call volume service line agreements and member satisfaction. The Director will work closely with the Performance and Data team to measure and scale care management programs and outcomes. The Director will lead with efficiency and clinical best practices in mind while ensuring the delivery of patient- and family-centered services and support. The position may include evening hours and travel throughout the eight-county service area of CCHA.

ESSENTIAL DUTIES:

• Provides leadership and direction on care navigation, coordination and management program design
• Serves in the capacity of Director of Care Coordination Key Personnel for the state contract
• Utilizes outcomes data to inform the development of care and condition management programs
• Creates proactive processes and policies to prevent the exacerbation of Member conditions and the escalation of Member situations
• Partners with Chief Clinical Officer, subject matter experts, and business owners as well as joint venture care coordination, utilization management, Chief Behavioral Health Officer and quality partners to achieve on care coordination and call center expectations as outline in ACC Phase III
• Participates in clinically focused calls, workgroups and meetings with internal and external entities
• Leads team employee engagement efforts as well as serves as a champion for the organization’s mission, vision, and values
• Facilitates effective communication, collaboration, and coordination between CCHA and, at a minimum, partner Case Management Agencies, Behavioral Health Administrative Services Organizations, and Dual Special Needs with the goal of ensuring comprehensive, effective and efficient coordination of care for jointly managed Medicaid Members
• Jointly oversees effective delivery of Care Coordination for Members by Network Providers, delegated and Subcontracted organizations, and others within the Health Neighborhood in collaboration with the Performance and Data team
• Adapts, develops and/or revises policies and procedures and promote their implementation across the organization
• Partners with joint venture and internal clinical leaders to develop and implement a care coordination model drive by a risk stratification methodology that aligns with the state tiers in ACC Phase III
• Works across teams to develop clinical programs that improve performance on ACC Phase III quality program measures
• Oversees the creation and provision of care coordination training and best practice delivery to delegated care coordination entities
• Responsible for oversight to ensure all clinical, care coordination and call center contractual requirements are delivered to the state on time and in a consistent and accurate manner
• Works with joint venture partner to meet RAE contract requirements and ensure adherence to state and federal regulations.
• Serves as care coordination subject matter expert for providers, partners and the community
• Manages Clinical Operations team including budget, staffing, mentoring and conflict resolution
• Responds to inbox, web form, phone and voicemail while meeting required inbound and outbound call and email response times.
• Adheres to the company’s Compliance Program and to federal and state laws and regulations
• Other duties as assigned

EDUCATION:

Master’s degree in Nursing, Healthcare Administration, Public Health, or related healthcare or business field.

Active unrestricted RN license  in the state of Colorado.

EXPERIENCE:

Minimum of six to eight years progressive experience in managing health care staff including RNs and Social Workers.

Three to five years direct Medicaid experience required

• Experience managing or coordinating inbound and outbound calls
• Extensive experience with NCQA standards and assessments across the continuum of member needs.
• Demonstrated experience working with primary care and behavioral health providers is required.
• Experience developing care management programs to support achieving HEDIS and/or CMS Core Measures required

Preferred experience include:

• Experience with Health First Colorado or Medicaid managed care programs
• Experience working in or leading care coordination activities at Medicare or Medicaid health plan

KNOWLEDGE, SKILLS, ABILITIES:

• Demonstrated ability to  lead people through strong vision setting, inclusive attitude for collaboration, and a mindset for growth and development of professionals.
• Impeccable presentation and written communication skills are required.
• Healthcare experience and knowledge of healthcare terminology, specifically related to Medicaid and Medicare
• Strong facilitation skills for small and large group engagements.
• Excellent communication and interpersonal skills (verbal and written) necessary to effectively interact with all levels of the organization and external entities.
• Able to juggle multiple projects that greatly differ in subject matter while exceling in time management and organization.
• Comfort using project management tools for managing performance and tasks.
• Remain flexible in work schedule to provide the most effective and efficient support for the organization and practices.
• Knowledge of NCQA, QA, Medicare/Medicaid guidelines, program and workflow development, process improvement and implementation procedures, care coordination, especially care transitions models and health coaching models
• Knowledge of the principles and practices of health planning and management sufficient to manage, direct and coordinate the operations of multiple interrelated departments in a health care organization.
• Knowledge of the policies and procedures of health plans, hospitals and physician organizations sufficient to interact with other health care providers effectively
• Skilled in exercising a high degree of independent initiative, judgment, discretion and decision-making to achieve organizational objectives
• Skilled in establishing and maintaining effective working relationships with employees, policy-making bodies, third party payers, patients and the public
• Skilled in leading others to excellence through effective communication of vision and feedback on performance
• Ability to communicate clearly with diverse audiences, from individual employees to the company Board of Managers.
• A valid unrestricted drivers’ license
• Great project management and organizational skills; must be able to coordinate multiple initiatives simultaneously to produce efficiencies.
• Proficient in Microsoft Office Suite.
• Experience using Power BI.
• Ability to support staff through change management and workflow transformation
  • Home office, that is HIPAA compliant for all remote or telecommuting positions as outlined by the company policies and procedures
• Position may require working outside of normal business hours at times
  • Travel: Up to 30%

Salary Range:

Salary Range: $114,857.60 - $164,080.80