Job description
Company Description:
Clearlink Partners is an industry-leading managed care consultancy specializing in end-to-end clinical and operational management services and market expansion initiatives for Managed Medicaid, Medicare Advantage, Special Needs Plans, complex care populations, and risk-adjusted entities.
We support organizations as they navigate a dynamic healthcare ecosystem by helping them manage risk, optimize healthcare spend, improve member experience, accelerate quality outcomes, and promote health equity.
Position Responsibilities:
Specific
Conduct clinical review of prior authorization, concurrent review, and retrospective review requests to determine medical necessity and appropriateness of services.
Collaborate with utilization management nurses and clinical staff to support timely decision-making.
Review appeals and grievances related to medical necessity and participate in fair hearing processes as required.
Ensure compliance with federal and state regulations, NCQA/URAC standards, and MCO policies.
Serve as a liaison between the medical management department and providers, offering guidance on clinical criteria and utilization trends.
Participate in interdisciplinary rounds and case review meetings as needed.
Identify utilization trends and contribute to the development of policies, clinical criteria, and medical management strategies.
Support quality improvement initiatives and population health programs as needed.
General
Provide strategic direction for health plan market/ product medical management and health service operational oversight, management and performance
Leverage advanced industry expertise and expert knowledge, grounded in research and industry best practice, to provide high value consulting and advisory services
Deliver innovative, integrated solutions in support of client goals and engagements.
Lead engagements ensuring completion of all contracted services
Present findings, recommendations and plans to Client executives
Facilitate complicated problem-solving discussions to drive to timely, effective decision making
Advise and persuade key decision makers and influencers
Deliver concise, clear interpersonal communication to both internal and external audiences
Facilitate streamlined executive summaries, next step recommendations and communication to all levels of Clearlink and client/ partner organization(s)
Articulate performance across multiple projects with qualitative and quantitative results/ outcomes
Influence others to best course of action through advanced understanding of changing business landscapes
Develop strategies, goals and plans in response to changing business conditions
Leverage best practice methodologies and approaches across individual account strategies/ client plans.
Establish short term KPIs and long-term goals and track progress to ensure achievement
Develop or update policies, procedures and workflows as required to support business needs and requirements
Coach and mentor staff to reach established engagement goals, plan deliverables and KPIs
Adapt process, approach, plan and/ or activities in real time to mitigate risk and ensure critical path activities
Support account management relationships with key client decision makers
Position Qualifications:
Competencies:
Advanced managed care industry expertise with C-Suite experience developing strategy, managing P&L, leading people, and ensuring contractual compliance
Ability to translate trends, innovation, operations, financing, costs, requirements and performance into scalable activities and repeatable outcomes
New product/ market strategy, design and implementation in the Commercial, Medicare, Medicare Advantage, Medicaid and/ or associated lines of business
New population strategy development including identification, program design and implementation
Operationalizing requirements for complex memberships, ensuring outcome delivery
Expert understanding of legal and regulatory frameworks, healthcare administration models, and internal audit procedures including compliance and remediation activity
Ability to interpret and educate on complex concepts, requirements and legislation such as the Knox-Keene Act and HIPAA, State Department of Insurance requirements, Federal and State Health and Human Services requirements/ standards as well as CMS, NCQA, and URAC to ensure compliance with complex regulatory structures.
Strategic leader with ability to produce, manage and maintain system-wide change through influence and persuasion
Advanced knowledge of project management principles, methods, and techniques
Ability to organize, prioritize, and manage multiple complex projects simultaneously
Excellent communication skills both written and oral
High proficiency with core office software (Excel, Word, and PowerPoint). Visio skills preferred
Experience:
Medical Degree (MD or DO) required;Must be actively licensed in Pennsylvania or New Jersey
Masters degree in Healthcare or Business Administration or related field Degree preferred
10+ years administrative leadership achievement in health plan operations with progressive responsibility.
CMO level experience preferred
7+ years of experience in a government payor environment with expertise in medical management practice with experience in multiple lines of business (Medicare, Medicaid, Healthcare Exchange, Commercial etc)
5+ years delivering results, managing teams and projects and mentoring other physicians in a health plan setting and/or consulting environment; driving complex, multi-faceted, multi-site, application/operational change/improvement programs and activities.
Physical Requirements:
Must be able to sit in a chair for extended periods of time
Must be able to speak so that you are able to accurately express ideas by means of the spoken word
Must be able to hear, understand, and/or distinguish speech and/or other sounds in person, via telephone/cellular phone, and/or electronic devices
Must have ample dexterity which allows entering of text and/or data into a computer or other electronic device by means of a keyboard and/or mouse
Must be able to clearly use sight so that you are able to detect, determine, perceive, identify, recognize, judge, observe, inspect, estimate, and/or assess data or other information types
Must be able to fluently communicate both verbally and in writing using the English language
Must be able to engage in continuous social interaction, successfully manage stressful high conflict situations, and balance multiple duties, expectations and responsibilities simultaneously
Time Zone: Eastern or Central
Other Information:
Expected Hours of Work: Friday 8am – 5 pm; with ability to adjust to Client schedules as needed
Travel: May be required, as needed by Client
Direct Reports: None
Salary Range: $100.00 - $150.00/ hr
EEO Statement:
It is Clearlink Partners’ policy to provide equal employment opportunity to all employees and applicants without regard to race, sex, sexual orientation, color, creed, religion, national origin, age, disability, marital status, parental status, family medical history or genetic information, political affiliation, military service or any other non-merit-based factor in accordance with all applicable laws, directives and regulations of Federal, state and city entities. This salary range reflects the minimum and maximum target wage for new hires of this position across all US locations. Individual pay will be influenced by Experience, Education, Specialized Soft Skills, and/or Geographic location.
Originally posted on Himalayas
Who can apply
Eligible countries: United States. Accepted UTC offsets: UTC-10, UTC-9, UTC-8, UTC-7, UTC-6, UTC-5, UTC+14. Review the full description for employer-specific work authorization, residency and schedule requirements.