UPMC is actively seeking a Senior Director, LTSS Clinical Operations for the Community HealthChoices team. This Senior Director will be accountable for the entire service coordination field covering the southeast region. This includes Bucks, Chester, Delaware, Montgomery and Philadelphia counties. The role will be based out of our Philadelphia office. We are looking for a proven leader that is experienced in Medicaid, Medicare, Managed Care and Long Term Support Services.
The Senior Director, LTSS Clinical Operations will manage the direction of activities related to the care management and service coordination of UPMC Community HealthChoices membership including long-term services and supports. The role provides day-to-day clinical operational support for the UPMC Community HealthChoices line of business related to the design, development, testing, and implementation of this new product. As well, the Senior Director is expected to give ongoing management of service coordination and Medicare-Medicaid service integration. They provide oversight of all clinical personnel and contractors supporting this product's operations.
Manage all aspects of Community HealthChoices service delivery.
Responsible for oversight of home and community-based services including service coordination.
Establish and oversee home and community-based services training in accordance with the care model across internal and external staff.
Work in close collaboration with the Community HealthChoices, Medicare, and D-SNP product teams.
Work in close collaboration with clinical leadership responsible for and with impact on D-SNP membership, institutionalized members, and the community team.
Develop and oversee contracted services
Function as liaison between UPMC and other non-UPMC contracted network facilities to ensure successful program management
Develop and oversee coordinated approaches to Medicare and Medicaid delivery to foster integration and improved member experiences including case management, utilization management, and holistic member engagement.
Communicate effectively in individual and group situations to ensure optimal implementation, and processes, interface with both internal and external providers, regulatory and compliance auditors, staff and members.
Develop tactical strategic plans for business units to optimize efficiency and achieve corporate business objectives.
Analyze and trend data to identify area of opportunity and implement process improvements.
Manage oversight, management and documentation of medical management quality work plan and annual program evaluation related utilization metrics and budget targets, quality metrics and regulatory requirements and as related to the technology utilized in the medical management department.
Develop, monitor and manage budgets related to clinical operations, system support and implementation projects.
Manage production, quality audit and management of reporting produced from the medical management department for external reviews for Health Management, i.e. DHS, DOH, CMS Medicare reviews.
Proactively identify risks and work with management staff to mitigate risk and implement corrective action plans as necessary.
Ensure operational performance within the clinical operations support area through analysis, critical decision making and implementation of automated solutions.
Partner with Information Systems management personnel to evaluate technology solutions, custom development and/or system implementation for internal and external customers.
Continuously evaluate and manage documentation of customer needs and all aspects of business processes to assure systematic processes are being utilized to capacity to optimize system efficiencies.
Analyze, evaluate and present information concerning factors, such as business situations, production capabilities and design and development of system processes to all customer levels within the organization.
Work with Senior Management to achieve efficiencies across integration of projects.
Develop and maintain work plans which include time, resource allocation, testing and implementation of new business, medical management programs or technology.
Represent clinical services on internal and external forums and committees, as requested.
Direct the liaison functions between the UPMC Health System and other network providers to ensure successful service coordination and utilization management processes.
Direct all processes implementation activities related to case management.
Master's degree required with five years experience supporting service coordination of long-term services and supports.
Five years of experience in management and in health care insurance or health care industry with regulatory, compliance and information system knowledge.
Experience with Medicare/Medicaid integration and Medicaid managed long-term services and supports preferred.
Proficient knowledge in MS Office and PC skills required.
Ability to demonstrate excellent organizational, interpersonal and communication skills.
Strong project management, problem-solving, organizational, and communication skills (oral and written) are required.
Ability to perform planning for large initiatives/projects, as well as manage all tasks required to meet departmental and business needs within budget and targeted deadlines.
Internal Number: 672444
About UPMC Health Plan
UPMC Health Plan, headquartered in Pittsburgh, Pa., is among the nation's fastest-growing health plans. It is owned by UPMC, a world-renowned health care provider. As part of an integrated health care delivery system, UPMC Health Plan is committed to providing its members better health, more financial security, and the peace of mind they deserve. UPMC Health Plan partners with UPMC and community network providers to produce a combination of knowledge and expertise that provides the highest quality care at the most affordable price. The UPMC Insurance Services Division — which includes UPMC Health Plan, UPMC WorkPartners, LifeSolutions, UPMC for Life, UPMC for You, UPMC for Kids, Askesis, and Community Care Behavioral Health — offers a full range of group health insurance, Medicare, Special Needs, CHIP, Medical Assistance, behavioral health, employee assistance, and workers' compensation products and services to over 3.2 million members. Our local provider network includes UPMC as well as community providers, totaling more than 130 hospitals and more than 20,000 physicians throughout Pennsylvania and parts of Ohio, West Virginia, and Maryland.