The Director of Clinical Services is responsible for the direct supervision of the Case, Disease and Utilization Management Departments for Third Party Administrators/Self Funded employer health plans. The Director Clinical Services is in charge of providing guidance and direction to the organization’s initiatives and implementation of goals, objectives, policies and procedures within the company that serve to support effective business operations. Focus will be given to developing Case and Disease Managers, Utilization Management Clinical Reviewers, and implementing actions to improve services to our clients.
Provides guidance and leadership for clinical operational aspects both the Case, Disease and Utilization Management Departments
Oversees clinical decision-making aspects of the of both Case/Disease Management and Utilization Management Departments.
Ensures compliance with regulatory and governmental standards
Provides monthly evaluation/data collection of the CM, DM and UM programs effectiveness and quality
This position dedicates at least 0.25 FTE to Quality Management activities
Participates in the Quality Program program of the CareValent.
Makes recommendations regarding: Hires, fires, educates, counsels, evaluates and salary increases and promotions for those under his/her supervision
Ensures CareValent has qualified clinicians who are accountable for their decisions affecting the members
Supports decisions made by senior management
Makes presentations to clients as scheduled
Assists with maintaining URAC Standards and Accreditation
Prepare client specific reports within specified timeframes
Manages cases when caseload dictates.
Performs all job functions within the scope of practice for the State or Jurisdiction in which RN license is held.
Minimum five (5) years as a Case Manager with Clinical Nurse Reviewer (utilization review) experience desirable
Management experience in CM/DM and UM programs
Minimum five (5) years Clinical experience
Case Management experience from the payer perspective
Certified Case Manager
Current unrestricted Registered Nurse license in the State of Florida (or state of residence)
Knowledge of Case/Disease Management and Utilization Management URAC standards preferred
Experience with TPA/Self Funded employer health plans
CareValent, a Payer Compass Company, recognizes the value of promoting health, preventing illness and providing state-of-the-art comprehensive medical management services. With more than 20 years in the medical risk industry, we are committed to improving the quality of health care and achieving the best health outcomes for our patients and clients.