Director, Health Services

Become a part of our caring community and help us put health first
 The Director, Health Services utilizes clinical skills to support the coordination, documentation and communication of medical services and/or benefit administration determinations. The Director, Health Services requires an in-depth understanding of how organization capabilities interrelate across the function or segment.

The Director, Health Services, uses clinical knowledge, communication skills, and independent critical thinking skills towards interpreting criteria, policies, and procedures to provide the best and most appropriate treatment, care or services for members. Coordinates and communicates with providers, members, or other parties to facilitate optimal care and treatment. Decisions are typically related to identifying and resolving complex technical and operational problems within department(s), and could lead multiple managers or highly specialized professional associates.

The role requires experience caring for patients with complex medical and social needs and an understanding of how to provide care more efficiently and effectively with an interdisciplinary team. We are looking for individuals who are passionate about transforming our care system for patients who need it most and are driven by doing well by doing what’s right. This candidate must be an insightful risk-taker willing to thoughtfully disrupt the status quo and excited to work in a rapidly evolving start-up environment.

The role of Director, Health Services will focus on the following areas:

• Serve as a thought leader in designing and implementing the interdisciplinary care team

• Develop and monitor all clinical protocols, either independently or in collaboration with other interdisciplinary care team members as relevant, for the care team to use for both in person and virtual (both tech-enabled and telephonic) care management, chronic disease management and care at points of transition

• Determine state dependent requirements and modify work of the care team as necessary to ensure compliance with all local policies and practices

• Oversees the hiring and management of a team in the market that provides direct member care

• Developing and implementing Clinical Prior Authorization policies, processes, detailed workflows, and leading the Utilization Management team. 

• Hiring and directly leading a team of Utilization Management nurses, clinicians and support staff responsible for reviewing and processing clinical authorizations and clinical claims reviews

• Assure compliance with state timeframes for turnaround times on authorization requests and delivery of Utilization Management services

Use your skills to make an impact
 

Required Qualifications

• Active Registered Nurse (RN) license, or Licensed Social Worker (LSW) licensed in the state of South …