LOCATION: Remote, however incumbent must be able to commute to Vaya's main headquarters in Asheville, NC
Position Description Summary:
The Utilization Management (UM) Physical Health Clinical Director is responsible for setting strategic direction, planning, budgeting, policy development and business process management and improvement for all Physical Health UM functions. This role works closely with the Chief Medical Officer (CMO), the Assistant Vice President (AVP) of Clinical Solutions and the BH/IDD/TBI UM Clinical Director to develop and advance the UM program, oversees delegated entity UM functions and supports initiatives with providers and members to ensure the appropriate utilization of services. Duties include management and oversight of all Physical Health UM staff to ensure adherence to Vaya policies and procedures in service plan reviews, authorizations and appeals. Responsibilities include maintaining current operations as well as preparation for and implementation of Tailored Plan services.
The UM Physical Health Clinical Director reports directly to the AVP of Clinical Solutions and develops and provides internal clinical training, consultation and supervision, and ensures all funded external training meets the strategic goals of the department.
Note: This position requires access to and use of Sensitive Information, including protected health information (PHI) as described in laws addressing patient confidentiality, including, but not limited to, the federal HIPAA law, the Confidentiality of Substance Use Disorder Patient Records regulations at 42 CFR Part 2, and various state laws. As such, the individual filling this position shall be required to be trained regarding such laws and shall be required to observe those laws in his/her capacity as an employee of Vaya Health. The individual filling this position shall also sign a confidentiality statement as an employee of Vaya Health.
Essential Duties and Responsibilities:
Oversight of Physical Health Utilization Management Functions:
- Provides strategic direction for and oversight of the day-to-day operations of the UM Physical Health Team
- Designs and develops UM policies and oversees monitoring and training of staff to ensure compliance with policies and accreditation standards
- Collects and monitors over and under-utilization data, with subsequent implementation of appropriate action in collaboration with relevant Vaya departments and stakeholder groups.
- Provides education and support to other Vaya departments about authorizations, denials, appeals, claims and clinical issues.
Supervision and Consultation:
- Provides clinical and administrative direction and support for the Physical Health UM Team
- Supports consistent application of clinical decision-making tools and criteria by Vaya staff and contractors
- Ensures staff performance standards are maintained and measured, with ongoing coaching and accurate performance documentation.
Leadership and Management:
- Ensures ongoing compliance with internal and external regulatory standards during current operations and in the future with Tailored Plan functions
- Serves as liaison to the Department for Vaya’s Physical Health IDD Clinical Programs
- Serves as a thought leader within the organization, collaborating with other Vaya departments and stakeholders to execute strategic goals and objectives
- Participates in Innovations Stakeholder meetings regularly and collaborates with Providers to achieve system goals
Other duties as assigned.
QUALIFICATIONS & CREDENTIALING REQUIREMENTS:
A Associate's Degree in nursing is required, a Bachelor's Degree in Nursing is preferred with Five or more years provision of direct patient care. Five or more years of experience in a management role. Must hold an active, unrestricted RN license in North Carolina.
Person in this position is required to have close visual acuity to perform activities that include viewing a computer terminal; and extensive reading. Physical activity in this position includes crouching, reaching, walking, talking, hearing and repetitive motion of hands, wrists, and fingers. Sedentary work with lifting requirements up to 10 pounds, sitting for extended periods of time.
Knowledge, Skills and Abilities:
This position requires exceptional interpersonal skills, effective communication, and the ability to make prompt independent decisions based upon relevant facts and established processes. Problem solving, negotiation and conflict resolution skills are essential. The UM Physical Health Clinical Director must be able to independently organize multiple tasks and priorities, and to effectively manage these under pressure of deadlines. Thorough knowledge of health principles, techniques, and practices, and their application to complex treatment and service provision is essential. The UM Physical Health Clinical Director must have the ability to engage providers in collegial discussions about plans of care and best clinical practices for members as well as the ability to interact professionally and effectively with persons who disagree with UM decisions. The UM Physical Health Clinical Director must be able to express ideas clearly and concisely orally and in writing, and to plan and execute work effectively and efficiently.
Must hold an active, unrestricted RN license in North Carolina.
SALARY: Depending on qualifications & experience of candidate. This position is exempt and is not eligible for overtime compensation.
DEADLINE FOR APPLICATION: Open until filled
APPLY: Vaya Health accepts online applications in our Career Center, please visit http://www.vayahealth.com/careers-overview/ Ind.001
Vaya Health is an Equal Opportunity Employer