REGIONAL CLINICAL DIRECTOR
At New Directions Behavioral Health, we hire the best and brightest. If you believe that healthcare should address the needs of the whole person, body and mind, we are looking for you! We are the fastest growing behavioral health care company and with good reason, we deliver results. We are dedicated to helping people find a healthy balance and improve their total health through positive change. We succeed because we are a team of creative, compassionate and talented individuals that believe in balance and a healthy lifestyle for ourselves and for those we serve. Join our team and be appreciated for your ideas and creativity. At New Directions, we embrace quality, innovation and risk-taking – all of the elements that drive change and support our mission: Improving health through change.
New Directions Behavioral Health is seeking a Regional Clinical Director for our office in Jacksonville, FL located on the Florida Blues campus. The Regional Clinical Director is responsible for the performance of the Utilization Management and Case Management functions for assigned books of business. Responsibilities include program development, quality control, implementation and maintenance of UM and CM policies, procedures and employee supervision and training.
This position initiates and participates in cross-functional collaborations with other departments, including Business Development, Account Management, Network Development, Customer Service, Information Services, Operations and Quality Improvement with the goal of promoting efficient and effective work flows and superior service to all customers.
This position manages the day to day functions of the Utilization Management and Case Management departments including preauthorization, concurrent review, discharge planning, engagement, care planning and care coordination. Assists in managing the denial and appeal process. This position is accountable to maintain utilization management and case management accreditations and compliance with regulatory requirements.
This position is responsible for promoting prompt problem resolution of utilization management and case management concerns and questions generated by health plan customers and is responsible for implementation and execution of health plan business according to contractual and regulatory requirements.
This position is responsible for utilization management and case management results including but not limited to meeting targets for over/under utilization, admit/1000, ALOS, readmissions and ambulatory follow up requirements. This position is responsible for utilization management and case management staff initial and ongoing training. Additionally, the position is responsible for performing quality audits to ensure compliance with policies and procedures and accurate and timely clinical documentation.*CB
The Regional Clinical Director Key Responsibilities includes:
- Maintains positive relationships with potential, new and existing health plans purchasing clinical services from New Directions Behavioral Health
- Works closely with Business Development and Account Management in implementing new business; specifically educating staff on changes and tracking and education of staff of benefit plans for health plans
- Works closely with New Directions customers; has accountability for building positive customer relationships through day to day collaboration as well as through regular joint meetings
- Manages ongoing relationships with health plan customers on UM and CM concerns promoting prompt and effective problem resolution
- Develops strategies for successful HEDIS outcomes for all customers
- Works closely with analytics to develop performance improvement strategies
- Works closely with high risk high cost members and establishes monitoring to see that members have individual care plans to meet member’s needs.
- Develops education programs for UM staff related to UM and CM policies and procedures, information systems, medical necessity criteria, peer review activity, care planning, engagement, cultural diversity and others. Works as a team-member with clinical management peer
- Assures UM and CM policies and procedures are in compliance with URAC, NCQA and new laws. Educates staff on any changes. Updates policies as needed
- Mentors and trains staff in administration of processes required by URAC/NCQA
- Works closely with information services to develop software and system changes to UM function
- Assists in the oversight of appeals and denials
- Coordinates with After Hours department to promote smooth and effective transactions between Customer Service, UM and CM departments to promote consumer and Provider satisfaction.
- Provides supervision to the UM and CM staff during the workday as assigned
- Works with Network Development staff to assist in communicating UM and CM policies and procedures to facilities and providers
- Works with trainers to orient new employees to New Directions and assists with developing programs for entire New Directions staff
- Identifies customer service issues and works with specific areas as needed to resolve issues
- Works closely with Chief Operating Officer related to claims process and improvement
- Responsible for health plan customer retention
- Executes health plan business in accordance with current contractual requirements
- Maintains accreditation status
- Meets utilization management department goals
- Responsible for educating and competency testing of UM and CM staff for knowledge of UM and CM processes required by NCQA/URAC and other regulatory bodies
- Administration of denial processes, compliant with NCQA/URAC and other regulatory bodies
- Maintains client confidentiality and provides supervision to staff such that client confidentiality is maintained
- Meets annual budget targets for administrative expense
- Maintains licenses, CEUs and certifications and required by applicable state laws and New Directions Behavioral Health
- Assumes other duties consistent with position and as directed by the Regional Vice President, Chief Medical Officer or President