UnitedHealth Group is an innovative leader in the health and well-being industry, serving more than 55 million Americans. Through our family of companies, we contribute outstanding clinical insight with consumer-friendly services and advanced technology to help people achieve optimal health.
Description
Ingenix is part of the family of companies that make UnitedHealth Group one of the leaders across most major segments of the US health care system.
If you get excited about the life transforming potential of bringing health care information to the right place, at the right time, to support crucial decisions, welcome to Ingenix.
We're one of the largest and fastest growing health information companies and the only organization in our industry with the information, technology and consulting expertise to solve the most significant challenges in health and human services.
As a vital member of the UnitedHealth Group family, we serve customers in every segment of the health care field. This includes government agencies, pharmaceutical companies, hospitals and health delivery networks, insurance providers and, of course, the diverse business divisions of UnitedHealth Group.
The Director of Clinical Operations is accountable for execution of AFRS clinical strategy, ensuring that Fraud, Abuse, and Waste solutions are clinically sound and effectively integrated with customers' clinical organizations. The incumbent applies deep clinical and health care industry knowledge to establish credibility and effective communication with clinical counterparts across all stakeholders. This position reports to the Vice President of Anti Fraud, Waste and Abuse.
Clinical Staffing
- Sets clinical performance standards and metrics, participates in clinical training/development, performance evaluation
and coaching of clinical staff assigned to the Fraud organization and global vendor
- Collaborates with AFRS Leadership, global vendor and Human Capital to ensure timely availability of sufficient clinical
resources to support continued growth and development of AFRS solutions
- Develop consistent Human Capital policies for clinical staff across the AFRS organization aligned with applicable UHG
policies
- Participates in interview process for clinical candidates and assists in positioning clinical staff in accordance with
abilities and strengths
Clinical Processes
- Ensures compliance with applicable state and federal regulatory standards, licensure requirements, and applicable
URAC and NCQA standards.
- Designs and implements clinical processes, including policies, procedures, customer reporting and performance metrics
- Oversees complex clinical initiatives, monitors and communicates status, escalates issues for resolution as appropriate
- Defines division of clinical operational work between Ingenix teams and vendors, continuously evaluate effectivness,
identify and address opportunities for improvement with focus on increasing value to customers through both
administrative cost reduction and enhancement of clinical capabilities
- Continually re-evaluates AFRSs clinical processes to identify opportunities for cost savings and quality improvement
- Defines sources and rationale for clinical information
- Standardize processes and tools to speed access to information and resolution of complex clinical issues in a manner
that selects the best clinical resource and considers the best use of clinical talent at all levels
- Ensures use of clinical data and analytics to drive fact based recommendations and decision making
Customer Implementation/Integration
- Develops a clear understanding of customer clinical organizations and processes, designs and implements effective
handoffs and integration points during new customer implementation and ensures that AFRS clinical processes rapidly
adapt to changes in customers' clinical organizations as appropriate on an ongoing basis
- Develops structured, repeatable methods, tools, and processes for use during implementation of new customers
- Serves as SME/point of contact for customers, participates in customer meetings as appropriate, and represents AFRS
on behalf of customers during audits and regulatory compliance site visits as needed
- Ensures measurement and communication of value delivered to customers including well crafted consultative
recommendations for customer consideration and action
Qualifications
Registered Nurse with active state license
BA/BS required, Masters preferred
10+ years experience in the health care industry including direct experience in a health plan/managed care environment, in addition, experience in a provider organization such as a hospital or physicians' office strongly preferred
Experience with management of complex teams and processes strongly preferred
Familiarity with regulatory and accreditation requirements and six sigma tools/processes
Excellent problem resolution skills
Experience in customer relationship management preferred
Solid presentation skills with proven experience in presenting complex information to clinical and non-clinical audiences
Proven effectiveness in interpersonal skills, influence, collaboration, and listening to understand customer needs.
Solid written and oral communication skills; ability to articulate issues in a concise manner.
Travel as required
Ability to apply deep clinical and health care industry knowledge to translate clinical strategy into action.
Ability to establishes trust with all stakeholders at all levels.
Ability to establish credibility with health plan customers
Contribution to net growth through customer retention and productivity, process-reengineering
Diversity creates a healthier atmosphere: equal opportunity employer M/F/D/V
UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment. In addition, employees in certain positions are subject to random drug testing.
