Managed Care Finance Director jobs in Clearwater, FL

Summary: Responsible for administration of all clinical aspects of the Quality Management Program; works closely with the CEO and Quality Management Steering Committee (QMSC) in administering the entire program. Provides guidance for all programs managed by the Health Services Department, Case Management, Disease Management and Utilization Management and assures that decisions are based on medical necessity, appropriateness and quality. Oversees processes for appeals and grievances, credentialing, and pharmacy services, providing clinical and leadership support. Develops relationships, solicits input from, and assists with education and recruitment of participating providers. Also participates in Health Services activities related to Government programs, including but not limited to: CMS, accreditation, and State and Federal guidelines by performing the following duties either personally or through subordinate supervisors.

Essential Duties and Responsibilities include the following. Other duties may be assigned.

Provides guidance for all clinical operational aspects of the program and for oversight of all clinical decision-making aspects of the program.

Responsible and accountable to the Company for decisions affecting the clinical services that the Company providers to their members

Communicates and periodically consults with practitioners in the field to assist in the development and maintenance of a strong, quality network of providers

Ensures the Company’s objectives to have qualified clinicians accountable to the Company for decisions affecting the member by:

· Individual consultations with providers

· Internal criteria review

· Documented peer-to-peer conversations

· Soliciting feedback from specialists

· Chairing the Medical Advisory Committee

Reviews and approves Company’s clinical review criteria and scripted clinical screening at least annually to ensure their continued appropriateness

Conducts peer clinical review for all cases where a clinical determination to certify any portion of the requested service cannot be met by an initial clinical reviewer

Documents and includes specific reasons for the non-certifications

Conducts, at least weekly, rounds with UR Nurses to discuss cases and provide communication regarding problematic case types

Conducts peer to peer conversation - clinical reviews for all cases where a certification of any portion of the requested service is not issued through the initial clinical review or initial screening (reconsideration)

Ensures that relevant policies and procedures as well as CMS, accreditation and state and federal program requirements are implemented to achieve effective, efficient, auditable, and compliant operations.

Interprets existing policies and develops new policies based on changes in the healthcare or medical arena.

Provides guidance for all programs related to authorization (pre-certification) of ancillary services and inpatient services and hospitals and skilled nursing facilities.

Provides guidance of the Utilization Management, Quality Management, Disease and Case Management Programs

Participates in the development, implementation and monitoring of quality improvement projects; for clinical projects, is involved in the selection/approval of clinical quality measures and clinical aspects of performance.

Chairs the Credentialing Committee, Medical Advisory Committee, Peer Review and other committees, as requested

Provides support for oversight of delegated clinical functions

Participates in accreditation activities

Oversees the development and implementation of all peer review activities

Has authority, accountability and responsibility for denial determinations for lack of medical necessity.

Consults with the board certified specialists in the specialty panel for review of complex utilization issues, as appropriate

Supports management staff, ensuring timely and consistent responses to members and physicians.

Uses clinical expertise to manage the clinical model, providing medical interpretation and decisions as required.

Identifies and analyzes medical information from multiple sources in order to develop interventions to improve the quality of care and outcomes.

Works with the medical community to assist in the development and maintenance of a strong, quality network of providers.

Reviews provider and member complaints, assist in resolution, and make recommendations for changes

Notifies Company in a timely manner of an adverse change in licensure or certification status

Supervisory Responsibilities

No direct reports.

Competencies

To perform the job successfully, an individual should demonstrate the following competencies:

Analytical - Synthesizes complex or diverse information; Collects and researches data; Uses intuition and experience to complement data; Designs work flows and procedures.

Design - Generates creative solutions; Demonstrates attention to detail.

Problem Solving - Identifies and resolves problems in a timely manner; Gathers and analyzes information skillfully; Develops alternative solutions; Works well in group problem solving situations; Uses reason even when dealing with emotional topics.

Project Management - Coordinates projects; Manages project team activities.

Technical Skills - Assesses own strengths and weaknesses; Pursues training and development opportunities; Strives to continuously build knowledge and skills; Shares expertise with others.

Customer Service - Manages difficult or emotional customer situations; Responds promptly to customer needs; Responds to requests for service and assistance; Meets commitments.

Interpersonal Skills - Focuses on solving conflict, not blaming; Maintains confidentiality; Listens to others without interrupting; Keeps emotions under control; Remains open to others' ideas and tries new things.

Oral Communication - Speaks clearly and persuasively in positive or negative situations; listens and gets clarification; Responds well to questions; Demonstrates group presentation skills; Participates in meetings.

Written Communication - Writes clearly and informatively; Edits work for spelling and grammar; Varies writing style to meet needs; Presents numerical data effectively; Able to read and interpret written information.

Teamwork - Balances team and individual responsibilities; Exhibits objectivity and openness to others' views; Gives and welcomes feedback; Contributes to building a positive team spirit; Puts success of team above own interests; Able to build morale and group commitments to goals and objectives; Supports everyone's efforts to succeed.

Visionary Leadership - Displays passion and optimism; Inspires respect and trust; mobilizes others to fulfill the vision; Provides vision and inspiration to peers and subordinates.

Change Management - Develops workable implementation plans; Communicates changes effectively; Builds commitment and overcomes resistance; Prepares and supports those affected by change; Monitors transition and evaluates results.

Delegation - Delegates work assignments; Matches the responsibility to the person; Gives authority to work independently; Sets expectations and monitors delegated activities; Provides recognition for results.

Leadership - Exhibits confidence in self and others; Inspires and motivates others to perform well; Effectively influences actions and opinions of others; Accepts feedback from others; Gives appropriate recognition to others.

Quality Management - Looks for ways to improve and promote quality; Demonstrates accuracy and thoroughness.

Business Acumen - Understands business implications of decisions; Displays orientation to profitability; Demonstrates knowledge of market and competition; Aligns work with strategic goals.

Cost Consciousness - Works within approved budget; Develops and implements cost saving measures; Contributes to profits and revenue; Conserves organizational resources.

Diversity - Demonstrates knowledge of EEO policy; Shows respect and sensitivity for cultural differences; educates others on the value of diversity; Promotes a harassment-free environment; Builds a diverse workforce.

Ethics - Treats people with respect; Keeps commitments; Inspires the trust of others; Works with integrity and ethically; Upholds organizational values.

Organizational Support - Follows policies and procedures; Completes administrative tasks correctly and on time; supports organization's goals and values; Benefits organization through outside activities; Supports affirmative action and respects diversity.

Strategic Thinking - Develops strategies to achieve organizational goals; Understands organization's strengths & weaknesses; Analyzes market and competition; Identifies external threats and opportunities; Adapts strategy to changing conditions.

Judgment - Displays willingness to make decisions; Exhibits sound and accurate judgment; Supports and explains reasoning for decisions; Includes appropriate people in decision-making process; Makes timely decisions.

Motivation - Sets and achieves challenging goals; Demonstrates persistence and overcomes obstacles; Measures self against standard of excellence; Takes calculated risks to accomplish goals.

Planning/Organizing - Prioritizes and plans work activities; Uses time efficiently; Plans for additional resources; Sets goals and objectives; Organizes or schedules other people and their tasks; Develops realistic action plans.

Professionalism - Approaches others in a tactful manner; Reacts well under pressure; Treats others with respect and consideration regardless of their status or position; Accepts responsibility for own actions; Follows through on commitments.

Quality - Demonstrates accuracy and thoroughness; Looks for ways to improve and promote quality; Applies feedback to improve performance; Monitors own work to ensure quality.

Quantity - Meets productivity standards; Completes work in timely manner; Strives to increase productivity; Works quickly.

Safety and Security - Observes safety and security procedures; Determines appropriate action beyond guidelines; Reports potentially unsafe conditions; Uses equipment and materials properly.

Adaptability - Adapts to changes in the work environment; Manages competing demands; Changes approach or method to best fit the situation; Able to deal with frequent change, delays, or unexpected events.

Attendance/Punctuality - Is consistently at work and on time; Ensures work responsibilities are covered when absent; Arrives at meetings and appointments on time.

Dependability - Follows instructions, responds to management direction; Takes responsibility for own actions; Keeps commitments; Commits to long hours of work when necessary to reach goals; Completes tasks on time or notifies appropriate person with an alternate plan.

Initiative - Volunteers readily; Undertakes self-development activities; Seeks increased responsibilities; Takes independent actions and calculated risks; Looks for and takes advantage of opportunities; Asks for and offers help when needed.

Innovation - Displays original thinking and creativity; Meets challenges with resourcefulness; Generates suggestions for improving work; Develops innovative approaches and ideas; Presents ideas and information in a manner that gets others' attention.

Qualifications To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and/or Experience

M.D. or D.O. from AMA Certified Medical School required; at least 2 years post-graduate experience in direct patient care and at least 2 years previous managed care experience required. Continuing education requirements are met through renewal of licensure by the FL Department of Health. At least 5 years previous practice experience required; at least 10 years of previous Managed Care and Medicare health plan experience and knowledge required, showing consistent and progressive responsibility and experience managing others.

Language Skills

Ability to read, analyze, and interpret common scientific and technical journals, financial reports, and legal documents. Ability to respond to common inquiries or complaints from customers, regulatory agencies, or members of the business community. Ability to write speeches and articles for publication that conform to prescribed style and format. Ability to effectively present information to top management, public groups, and/or boards of directors.

Mathematical Skills

Ability to work with mathematical concepts such as probability and statistical inference, and fundamentals of plane and solid geometry and trigonometry. Ability to apply concepts such as fractions, percentages, ratios, and proportions to practical situations.

Reasoning Ability

Ability to define problems, collect data, establish facts, and draw valid conclusions. Ability to interpret an extensive variety of technical instructions in mathematical or diagram form and deal with several abstract and concrete variables.

Computer Skills

To perform this job successfully, an individual should have expert working knowledge of Microsoft Office software, including Microsoft Excel, Access, and Word as well as MS Internet Explorer.

Certificates, Licenses, Registrations

Current, unrestricted Florida professional license; board certification (or meets Company’s credentialing standards).

Other Skills and Abilities

Some local travel required; provider and /or office visits

Other Qualifications

Physical Demands The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this Job, the employee is regularly required to talk or hear. The employee must occasionally lift and/or move up to 10 pounds.

Work Environment The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The noise level in the work environment is usually quiet.

We offer competitive compensation and benefits packages for qualified candidates. Join our team of dedicated healthcare professionals and make a difference in the lives of patients. Apply now!

Job Type: Full-time

Pay: From $270,000.00 per year

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Schedule:

• Monday to Friday

Experience:

• Quality Management Program: 1 year (Preferred)
• HEDIS: 3 years (Required)
• Managed care: 1 year (Required)

License/Certification:

• Medical License (Required)

Work Location: In person