VP of Clinical Operations - Behavioral Health
Showe and Associates, San Diego, CA
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- Manage criteria-based reviews of care, clinical appeals regarding medical necessity, and the interaction with claims payment policies and processes.
- Support goals, contracts, and accreditation requirements of health plan by conducting reviews of clinical interactions and clinical documentation including reviews of case management, utilization management, vendor, and provider records.
- Collaborate with local and national leaders including quality improvement, analytics, finance, network, ensuring a comprehensive approach to managing quality of care, service, and cost of care.
- Provides expert input to finance regarding patterns of utilization and cost and high cost cases.
- Manages a 24/7 crisis call center.
- This person will have 2 Managers and a team of 50-60 staff reporting into the position.
- Licensure to also include one of the following: RN, BCBA, LCMFT, LCSW, LPC or RN
- 5+ years experience in behavioral health operations including managing a call center
- 3+ years Behavioral Health leadership including mentoring and training staff
- A background that includes strong clinical work, experience in managed care and managing a call center team
- A depth of experience and strong understanding of managed care referral requirements
- A strong familiarization with Medicare guidelines and authorization processes
- Utilization management experience in an outpatient clinical environment.
- Knowledge of ambulatory healthcare delivery and management.
- Working knowledge of NCQA, and health plan requirements related to utilization management.
- A strong understanding of ambulatory healthcare delivery and management
- Demonstrated knowledge of prospective authorization process and workflow
- A track record of accomplishment in handling multiple competing priorities
- Working knowledge of Microsoft Office Suite, including Windows
- High energy with demonstrated accomplishment in working independently and in a team environment
- Experience overseeing contractual performance standards
- Strong background in the reporting and analysis of managed care utilization data
- Strong analytical skills
- A track record of accomplishment managing Behavioral Health UM teams
- Strong communications and leadership skills
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